Veno-occlusive disease, nodular regenerative hyperplasia and hepatocellular carcinoma after azathioprine treatment in a patient with ulcerative colitis

We report the case of a 66-year-old male with ulcerative colitis diagnosed in 1987, who had been treated with azathioprine (AZA) for the past two year s (average dose about 1.6 mg/kg/day), In May 1999 he presented with painles s jaundice, fatigue and recent weight loss. Cholestatic enzymes were elevat ed, alpha -fetoprotein was normal and hepatitis B/C serology negative. Afte r diagnosis of veno-occlusive disease (VOD) and hepatocellular carcinoma (H CC) via biopsy, tumour resection was performed. The histology was typical f or a well-differentiated HCC with trabecular and pseudoglandular structures . Neighbouring liver tissue was atrophic, with nodular regenerative hyperpl asia (NRH), peliosis-like sinusoidal ectasias and intra-sinusoidal accumula tion of blood, associated with peri-sinusoidal fibrosis, Although none of t he well-established risk factors for HCC such as cirrhosis, hepatitis B/C, metabolic liver disease or toxins were present, this patient developed HCC. This and previous reports suggest that NRH and/or VOD associated with AZA represent a risk factor for HCC. AZA should therefore not only be stopped i n patients with NRH/VOD but patients should also be screened for HCC. Eur J Gastroenterol Hepatol 13:287-290 (C) 2001 Lippincott Williams & Wilkins.