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Ranitidine-induced Hepatitis: A Rare Cause of Hepatotoxicity
Tae Lee, MD,1 Kenneth Vega, MD,2 Joe Khoury, MD1. 1. Internal Medicine/Gastroenterology Division, Marshall University JCESOM, Huntington, WV; 2. University Of Florida/Jacksonville, Jacksonville, FL.
Purpose: Introduction: Ranitidine and other histamine 2 receptor antagonists (H2RA) remain in use for acid-related disorders. This drugclass is considered extremely safe, resulting in use without a prescription. Despite this, it is rarely associated with severe hepatotoxicity.
Case: A 27 year old male, without significant past medical history, presented to Cabell Huntington Hospital with jaundice and mild RUQ discomfort of three days duration. Medication use at presentation was over-the-counter (OTC) ranitidine for intermittentepigastric pain and heartburn only. Active alcohol or drug use was not reported by the patient. Physical examination was significant for clinical jaundice and mild RUQ tenderness. No hepatosplenomegaly was noted. Laboratory data revealed a WBC count of 4.3103/mm3, AST of 1385 U/L, ALT 2544 U/L, total bilirubin of 10.7 g/dl, direct bilirubin of 7.5 g/dL, alkaline phosphatase 199 U/L, ferritin>1650 ng/ml, iron saturation of 62.1%., PT 14.5 seconds and INR 1.47. Acute viral hepatitis panel was negative. CMV and EBV serologies along with anti-mitochondrial, anti-nuclear and anti-smooth muscle antibodies were negative. Alpha-1-antitrypsin and ceruloplasmin serum levels were normal. HFE gene mutation was negative. Abdominal CT discovered a 6mm gallstone only. ERCP revealed a normalcholangiogram without ductal dilation, choledocholithiasis or sludge. Liver biopsy showed mild portal inflammation, predominantly small lymphocytes and a few eosinophils with mild lobular inflammation. Intrahepatic cholestasis was present, but no viral cytopathic effects or evidence of iron overload. Trichrome stain demonstrated minimal portal fibrosis. These findings suggested drug-induced hepatitis,likely due to ranitidine, as the sole medication used. This was discontinued at admission. All laboratory abnormalities at presentation returned to the normal range over the following 7 weeks.
Discussion: Ranitidine-associated acute hepatitis has been estimated to occur in less than 1 per 100,000 patients and appears to be idiosyncratic in nature. In most reported cases, the association was not cleardue to confounders including other potential hepatotoxic medications at presentation, recent vaccination or preexisting liver disease. Other cases had incomplete evaluation including the absence of liver biopsy, autoimmune or viral serologies as well as lack of endoscopic or radiologic biliary tree evaluation.
Conclusion: This case highlights the seriousness of drug-induced hepatitis caused by awidely used OTC medication. All clinical symptoms and biochemical abnormalities disappeared within 2 months of ranitidine withdrawal.
http://www.nature.com/ajg/journal/v104/n3s/full/ajg2009492_7a.html

Hepatitis Ranitidine-inducida: Una Causa Rara de Hepatotoxicity
Tae Sotavento, MD, 1 Kenneth Vega, MD, 2 Joe Khoury, MD1. 1. División de Medicina/Gastroenterología Interna, Universidad deMariscal JCESOM, Huntington, WV; 2. Universidad de Florida/Jacksonville, Jacksonville, FL.
Objetivo: Introducción: Ranitidine y otro histamine 2 antagonistas de receptor (H2RA) permanecen en el empleo para desórdenes relacionados con el ácido. Esta clase de medicina es considerada sumamente salvo, causando el empleo sin una prescripción. A pesar de esto, raras veces es asociado con hepatotoxicitysevero.
Caso: Un macho de 27 años, sin historia significativa médica pasada, presentada a Cabell Huntington Hospital con ictericia e incomodidad suave RUQ de tres duración de días. El empleo de medicación en la presentación era sin receta médica (OTC) ranitidine para el dolor de epigastric intermitente y el ardor de estómago sólo. El alcohol activo o el empleo de medicina no fueron relatados por el...