What Are Granulomas Of The Liver?

Granulomas of the liver, or granulomatous hepatitis, are little clusters of white blood cells, otherwise known as inflammatory cells, within the liver. Granulomas are not a type of cancer and generally form as a result of inflammation or infection in a patient.

The liver is a common area for granulomas to form due to the immune cells that reside there. When these immune cells cannot clear the underlying cause of the inflammation from the liver, more inflammation is triggered. This results in more immune cells traveling to the site and the formation of the granuloma. Granulomas are found within around 2% to 10% of liver biopsies.¹

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Symptoms of granulomas in the liver

Liver granulomas are usually asymptomatic — you might not have any symptoms. Most of the time, blood tests won’t pick up on it either. 

Potential symptoms of hepatic granuloma may include enlarged liver and mild jaundice in a patient.

Diagnosis of hepatic granulomas

To diagnose a patient with liver granulomas, doctors usually use liver imaging tests and can also order a liver biopsy. 

If a medical professional suspects that you have hepatic granulomas, they may also ask you about your lifestyle habits, such as drug use, and any family or personal history of other disorders that may be the cause of a granuloma.

Blood tests can also be used to monitor liver activity, in addition to liver imaging, through the use of magnetic resonance imaging (MRI), ultrasound, or computed tomography (CT) scans. 

Sometimes, even with the use of these tools, tests are inconclusive, and a liver biopsy may need to be taken. This process involves the removal of a small amount of liver tissue, which can then be looked at under a microscope to see if granulomas are present. 

Causes of hepatic granulomas

The formation of hepatic granulomas can be the result of a number of causes. Infections and the use of drugs are common causes of granulomas.

Drugs such as allopurinol, quinidines, and sulfonamides are commonly used by people who go on to develop liver granulomas. 

Infections with diseases such as schistosomiasis and tuberculosis are common causes of liver granulomas. Hepatitis C and cytomegalovirus infection are also common viral infections that can result in hepatic granulomas. 

Another common cause of liver granulomas is primary biliary cholangitis (PBC). 

The most common noninfectious reason for the development of hepatic granulomas is sarcoidosis, which affects the liver in two-thirds of these patients.

Typically, the cause of liver granulomas falls into one of five categories:

  • Idiopathic causes: the exact cause remains unknown, such as idiopathic granulomatous hepatitis

  • Malignancies: carcinoma, Hodgkin’s lymphoma, and non-Hodgkin’s lymphoma

  • Infectious diseases: mycobacteria (tuberculosis), leprosy bacteria, cat scratch disease, Q-fever, syphilis, listeria, fungal infections such as cryptococcosis, and aspergillosis; and viruses such as cytomegalovirus, hepatitis A and C, as well as Epstein–Barr virus can also lead to hepatic granulomas. 

  • Systemic diseases: sarcoidosis, chronic granulomatous disease, systemic lupus erythematosus, polymyalgia rheumatica, Crohn’s disease and ulcerative colitis; and liver diseases such as steatosis, primary biliary cirrhosis, primary sclerosing cholangitis, and hypersensitivity cholangitis are also causes of hepatic granulomas.

  • Reactions to drugs and other chemicals can also cause granulomas of the liver.

The four main types of hepatic granulomas

1. Caseating granuloma

A caseating hepatic granuloma is characterized by dying cells that damage the tissue. The affected tissue develops a soft cheesy texture.

2. Non-caseating granuloma

Non-caseating liver granulomas generally have no region of necrotic cells and are more common in sarcoidosis than in other diseases. 

3. Fibrin ring granuloma

Fibrin ring granulomas are typically uncommon in liver biopsy findings. Fibrin ring granulomas are made up of rings of fibrin and immune cells that surround a central region of fat. This type of liver granuloma is usually the result of drug use, infection, or Hodgkin’s lymphoma.

4. Lipogranuloma

Lipogranulomas consist of a number of immune cells that surround an area of lipid (fat). These usually form as a reaction to the ingestion of mineral oils from medications and foods. They can also occur as a result of immune cells absorbing droplets of fat from liver cells in fatty liver disease.

What is a calcified granuloma?

Calcification of granulomas occurs in the liver. The process of calcification refers to the accumulation of calcium deposits within a certain region of the body or organ, in this case, within granulomas of the liver. 

Not all granulomas become calcified. However, it can occur and will show up on CT scans or X-rays.

Similar to non-calcified granulomas, calcified granulomas are usually asymptomatic. 

Generally, calcified liver granulomas are benign and don’t require treatment. However, your doctor may order some tests to determine why your body formed the calcified granulomas in the first place. 

Treatment of calcified granulomas of the liver is the same as in non-calcified granulomas. Antibiotics or corticosteroids are usually prescribed, and the medication is determined by the underlying cause.

Treatment for liver granulomas

The best method of treating a hepatic granuloma differs for each cause. Treatment of liver granulomas targets the underlying reason for inflammation and is dependent on the disease present.

Asymptomatic or incidental findings of liver granulomas are generally monitored by a medical professional. Additional tests, such as liver function blood tests, may be ordered. 

In most patients, corticosteroids are a good treatment option. Doctors may prescribe steroids such as prednisone. For people who may not respond well to corticosteroid treatment, doctors may prescribe medications such as methotrexate or infliximab.

In patients for which the reason for liver granuloma development is infection, antibiotics may be prescribed by a doctor.

For people who have developed liver granulomas as a result of tuberculosis infection, a combination of medications is usually prescribed. 

Complications associated with liver granulomas

Hepatic granulomas can lead to complications. Granulomas of the liver can lead to the development of fibrosis of the liver, high blood pressure, or cirrhosis. This is dependent on how severe the granulomas are and the underlying reason behind their development.

In order to have the best outcomes for liver granulomas, it’s important that patients seek diagnosis and treatment quickly. 

Some cases of hepatic granulomas require therapy and may resolve quickly or require lifelong therapy to ensure proper functioning of the liver. 

The lowdown

Liver granulomas are regions of inflammation that can develop within the liver. Liver granulomas have numerous causes, and each cause has different treatments. Granulomas of the liver are common and are usually asymptomatic.

Doctors diagnose liver granulomas using a variety of methods, including liver biopsy, blood tests to assess liver function, and a variety of liver imaging technology, such as CT scans or MRIs. The causes of liver granulomas are not fully understood, and more research is required to fully understand why they occur.

Frequently asked questions

What does granuloma of the liver mean?

If an individual has granulomas present in the liver, this means that regions within the liver are colonized by inflammatory cells. Liver granulomas are common and found within 2% to 10% of liver biopsies.

What causes granulomas of the liver?

Typically, liver granulomas are associated with several causes. These come under the categories of infectious diseases, malignancies, idiopathic causes, systemic diseases, and reactions to various drugs and chemicals.

How do you treat liver granuloma?

The treatment required for liver granulomas depends on the cause. Usually, an underlying reason for the development of hepatic granulomas exists, and each cause has specific treatments. 

Typically, a doctor can prescribe corticosteroids or antibiotics for treating liver granulomas, depending on the cause.

Are liver granulomas serious?

Typically, liver granulomas don’t cause symptoms or other problems. However, the underlying causes of liver granulomas may lead to further problems. Liver granulomas, if left untreated, can go on to cause further problems such as blockage of the liver ducts or liver scarring and cirrhosis.

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