LUPUS AND THE LIVER

Article by Daniel J. Wallace, M.D., Associate Clinical Professor of Medicine, UCLA School of Medicine, appeared in Lupus News, Volume 13, Number 3)

"Involvement of the liver in SLE is a frequently misunderstood complication of the disease. The liver can be affected as a result of lupus itself, as well as the medications used to treat inflammation caused by lupus. ..."Lupus can affect the liver in numerous ways ...

ENLARGEMENT of the liver ... is found in 10% of SLE patients. The liver is rarely tender unless the enlargement is so great that the... covering of the organ is stretched. The most common cause of large livers in lupus include lupoid hepatitis, congestive heart failure, or cirrhosis."

"JAUNDICE ... is seen in 1-4% of patients with SLE. ... jaundice results from autoimmune hemolytic anemia, viral hepatitis, cirrhosis, or bile duct obstruction (from gallstones, tumor or pancreatitis). Occasionally, certain medications including nonsteroidal anti-inflammatory drugs and azathioprine may produce jaundice."

"HEPATIC VASCULITIS, or inflammation of the small and medium sized arteries of the liver, is extremely rare and is noted in one lupus patient per thousand. It responds to corticosteroids."

"BUDD-CHIARI SYNDROME (which is very rare) results from a blood clot in the portal veins which drain materials from the liver. Lupus patients with the lupus anticoagulant, anticardiolipin antibody, or antiphospholipid syndrome appear to be uniquely at risk for developing these clots. Additionally, hepatic artery clots may occur. ... The preferred treatment of Budd-Chiari syndrome is anticoagulation (blood thinning)."

"ASCITES is a term which refers to fluid in the abdomen... Often associated with serositis ..., ascites ... is noted in 10% of patients with SLE. Usually reflecting active disease, it may be painless or painful and can be mistaken for a "surgical abdomen" resulting in unnecessary surgery. If an infection is ruled out, ascites is treated with anti-inflammatory medication, gentle diuresis and occasionally periodic drainage. Ascites also may result from liver failure or nephrotic syndrome."

"ABNORMAL LIVER FUNCTION TESTS may be found in 30-60% of patients with SLE. Blood enzyme evaluations included in routine blood panels ... may be slightly elevated as a result of a variety of mechanisms. First of all, nearly all nonsteroidal anti-inflammatory agents, as well as aspirin, can elevate these enzymes, and lupus patients appear to be particularly susceptible to this. These minor abnormalities are usually of little consequence and I ignore them unless they are greater than three times normal. Also, active lupus can elevate these enzymes. Most nonsteroidals can be stopped for a week or two and the enzymes rechecked. If they remain increased, the possibilities... include hepatitis, infection, biliary disease, alcoholism or active lupus."

"This leaves us with the most perplexing problem to discuss:

LUPOID HEPATITIS ... has undergone many changes in definitions.... The current working definition of lupoid hepatitis is:

a) liver pathology consistent with chronic active hepatitis

b) absence of evidence for active hepatitis virus A, B or C infection

c) a positive ANA or LE cell prep

Even using these criteria, only 10% of patients at the Mayo Clinic fulfilled the American College of Rheumatology (ACR) criteria for SLE. Although fevers, joint aches, malaise and loss of appetite are common (as well as jaundice with itching), many of the physical findings we associate with SLE (rashes, other organ involvement) are usually absent. This is further complicated by the knowledge that lupus patients have compromised immune systems and can develop a viral hepatitis, take liver-toxic medications, and some abuse alcohol just as non-lupus patients do, which can lead to a chronic active hepatitis. "

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