Near-fatal spontaneous hepatic rupture associated with anabolic androgenic steroid use: a case report

Abstract

Anabolic androgenic steroids are commonly used at high doses by bodybuilders and athletes to enhance physique and improve performance levels. We report a case of spontaneous hepatic rupture with life-threatening haemorrhage associated with a past history of anabolic steroid use.A nabolic androgenic steroids (AAS) are commonly used in high doses by bodybuilders and athletes to enhance physique and improve performance levels. These agents are known to produce changes in various organ systems and cause adverse effects such as gynaecomastia, hypertension, ischaemic heart disease, psychological disturbances, testicular atrophy and acne.1 They have also been associated with prostate cancer and nephroblastoma.2-4 AAS also have a profound impact on the liver, including peliosis hepatis, cholestasis and hepatocellular adenomas. 5 We report a case of spontaneous hepatic rupture with life-threatening haemorrhage associated with a history of anabolic steroid use. CASE REPORTA 43-year-old man was brought to the accident and emergency department after he collapsed at home. He had the physique of a professional bodybuilder. He reported that he had epigastric pain for 2 days before the collapse. There was no history of trauma. On examination, he was found to be markedly tender over the epigastric and left hypochondrial areas. On arrival, he had a heart rate of 124 beats/min and a blood pressure of 69/ 30 mm Hg. He was conscious and alert with an oxygen saturation of 100%. Investigations revealed a haemoglobin of 10.6 g/dl, an international normalised ratio of 4.2, creatinine of 148 mmol/l and bilirubin of 27 mmol/l. All other parameters were within normal limits. The patient was resuscitated in the accident and emergency department with intravenous fluids and was transferred to the high dependency unit. His medical history included Crohn's disease and a recurrent deep vein thrombosis related to a familial thrombophilia for which he took warfarin and anabolic steroids. He had stopped taking steroids 4 years previously. He had been taking AAS for 25 years, which included nandrolone decanoate, stanozolol, primabolin and most forms of testosterone. By comparison with the doses taken in the bodybuilding fraternity, his consumption was at the low end of the range of steroid usage. Before a computed axial tomography scan was performed, he had a cardiovascular collapse that required aggressive resuscitation with blood products and intravenous fluids, and he underwent an emergency laparotomy. Three litres of blood was evacuated from his abdomen. A ruptured subcapsular haematoma of the liver was identified as the source of the haemorrhage. The abdomen was packed as the haemorrhage was difficult to control, being aggravated by the raised international normalised ratio. His postoperative period was complicated by sepsis, and acute renal and cardiovascular failure requiring renal and inotropic support. Re-exploration of his abdomen at 72 h was uneventful. He subsequently made an uncomplicated but slow recovery, being extubated at 10 days an...

The injecting use of image and performance-enhancing drugs (IPED) in the general population: a systematic review

“…), hepatic rupture (Patil et al . ) and psychiatric symptoms, such as aggression, recklessness and depression (Pagonis et al . , Lindqvist et al .…”

“…Significantly, multiple recent controlled studies which used cardiac magnetic resonance imaging (Luijkx et al 2013) or cardiography (Hassan et al 2009, Montisci et al 2012 have found cardiomyopathy in AAS users. In addition to the widespread incidence of cardiac effect, the literature also reports instances of cerebral stroke (Shimada et al 2012), hepatic rupture (Patil et al 2007) and psychiatric symptoms, such as aggression, recklessness and depression (Pagonis et al 2006, Lindqvist et al 2013, Cole et al 2003. Less critical side effects have also been evidenced to include rhabdomyolysis (Farkash et al 2009), lipogranualomatus reaction (Weinreb et al 2010), compartment syndrome and wound dehiscence (Joynes 2010), and abscess (Advisory Council for the Misuse of Drugs (ACMD) 2010, Marquis & Maffulli 2006).…”

Long-term psychiatric and medical consequences of anabolic–androgenic steroid abuse: A looming public health concern?

“…Use of 17-alpha alkylated AAS (which are orally active) is definitely, albeit rarely, associated with adverse hepatic effects, such as peliosis hepatis (Karasawa et al, 1979), intrahepatic cholestasis (Kafrouni et al, 2007; Sanchez-Osorio et al, 2008), hepatocellular adenomas or carcinomas (Bagia et al, 2000; Gorayski et al, 2008; Socas et al, 2005; Velazquez and Alter, 2004), hepatic angiosarcomas (Daneshmend and Bradfield, 1979; Falk et al, 1979) and spontaneous hepatic rupture (Patil et al, 2007). Adverse hepatic effects with non-17-alpha alkylated AAS, such as testosterone, appear to be extremely rare, but have been described (Carrasco et al, 1985).…”

The diagnostic dilemma of pathological appearance and performance enhancing drug use

“…AAS use is often discussed as a subset of APED use and the majority of scientific, clinical, and public attention has focused on this single drug class. AASs have obtained notable public interest due to scandals involving professional and Olympic athletes (Catlin et al, 2008; Tsitsimpikou, et al, 2009) as well as tragedies involving suicide/homicide, cardiac events, or other severe psychiatric or medical complications (Cowan, 1994; Dickerman et al, 1995; Hausmann et al, 1998; Huie, 1994; Patil et al, 2007; Peet and Peters, 1995; Santamarina et al, 2008; van Breda et al, 2003). Currently, there is no formal category of AAS or APED misuse in the Diagnostic and Statistical Manual for Mental Disorders-4 th edition ( DSM-IV ; American Psychiatric Association, 1994), but AASs are listed as an “other” substance in the SUD subsection.…”