Spontaneous hepatic rupture associated with the use of anabolic steroids.

Anabolic–androgenic steroids (AAS) are synthetic compounds that are structurally related with testosterone. They promote the development of male secondary sex characteristics and accelerate muscle growth. In the United States, approximately 2.9% of young people have used AAS, and among people who work out in gyms this percentage ranges from 15% to 30%. Similar data have been reported in several European countries. The improper, surreptitious abuse of these substances can have important health consequences. Athletes and body-builders use these compositions in high doses in order to increase their muscle mass and strength to improve performance. AAS cause changes in the organism, causing gynecomastia, ischemic heart disease and testicular atrophy. They also affect the liver, resulting in peliosis, cholestasis, hepatocellular adenoma and liver tumors. We present the case of a 30-year-old male body-builder who came to our Emergency Department due to asthenia, abdominal pain, nausea and vomiting. He had a long-term history of synthetic steroid and hormone use. On the initial assessment, the patient presented tachycardia and hypotension and was pale, perspiring and tachypneic. On physical examination, the abdomen was painful to palpation in the right hypochondrium and hepatomegaly was detected. The lab work-up showed leukocytosis 20 310/ml, Hb 8.2 g/dl, platelets 235 000/ml, creatinine 3.21 mg/dl, ALT 390 U/l, AST 602 U/l. Abdominal ultrasound revealed hepatomegaly and liver parenchymal destruction. The patient was admitted to the Intensive Care Unit for monitoring, transfusion and treatment with vasoactive drugs. Computed tomography (CT) revealed hepatomegaly and destruction of the right liver lobe. The repeated work-up showed Hb 5.9 g/dl, platelets 97 000/ml, ALT 1693 U/l, AST 3223 U/l and act. prothrombin 37%. The patient was therefore transferred to our hospital due to liver failure and the possible need for liver transplantation. A second CT confirmed hematoma of the liver with active bleeding and hemoperitoneum. Given these findings, an arteriography of the right hepatic artery was done, which showed no signs of active bleeding; even so, diffuse embolization was performed on the right hepatic artery (RHA) (Fig. 1). The patient evolved with progressive increase of the intraabdominal pressure and anuria. Due to this, we decided to perform urgent surgery. The approach was midline supraumbilical and transverse laparotomy on the right side. Evidence was observed of hemoperitoneum and subcapsular hematoma of the right liver lobe with active bleeding. The RHA was ligated and perihepatic packing used, and the abdomen was left open with a Bogota