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What Causes Starry Liver (Granulomas)?

Granulomas, either calcified or uncalcified spots on the liver, may be identified during imaging studies of the patient’s liver and/or spleen ultrasound test, CT or MRI scans. Because the liver usually maintains a uniform appearance on such imaging studies, the doctor easily identifies spots that are visually different from the rest of the liver’s tissue. GI North, a board-certified gastroenterology practice, supports patients’ digestive health and well-being.

What are the causes of a liver granuloma?

The National Institutes of Health (NIH) say that presence of these liver spots may indicate a serious disease process or provide evidence of prior infection, inflammation, or medication.

Scientists believe that granulomas result from infectious diseases, inflammation, cancerous or benign tumors, or medicines that the patient has taken over time. In most cases, the identification of granuloma prompts the doctor to perform other tests to identify the reason for the presence of one or more spots on the liver. When a granuloma is calcified—generally thought to be the body’s way of protecting itself from these spots—the imaging study may look like “stars” against the night sky.

For this reason, doctors refer to granuloma of the liver or spleen as “starry liver” or “starry spleen.” The liver may attempt to rid itself of these spots by pushing them to the spleen’s repository.

What diseases or conditions will the doctor look for if I have a starry liver?

Dr. Simon Cofrancesco of GI North will take a complete medical history to determine prior infection diseases, inflammatory diseases, tumors, or medicines the patient has used in the past. There are some parts of the United States (such as the Ohio Valley) in which some diseases occur with higher frequency than elsewhere and these infectious diseases can cause the patient to develop a granuloma.

He will then evaluate the patient for certain other conditions that are associated with the development of granuloma, including:

Hemangioma, a type of benign tumor that’s comprised of malformed blood vessels that formed before birth. This congenital defect occurs more frequently in women and may become apparent at any time of life. The presence of hemangiomas often correlates strongly to the presence of liver granuloma. There is rarely any reason to treat the hemangiomas if they are found unless blood vessels within the structure burst.

The doctor will also look for other noncancerous liver tumors, such as liver adenomas, also known as hepatocellular adenomas. Some women using oral contraception methods develop these tumors. In most cases, these tumors resolve once the patient stops taking oral contraceptives but granuloma may remain.

Inflammatory processes and diseases are also likely to leave granuloma of the liver in their wake. They may form when the liver suffers infection from an array of diseases, including cryptococcosis, tuberculosis, tularemia, schistosomiasis, toxoplasmosis, cat scratch disease, and syphilis, according to “The Merck Manual for Healthcare Professionals.” Granuloma may form in the aftermath of resolution of disease or, in some instances, may form over an infected area of the liver.

The doctor may order tests to identify the presence of infectious disease. If the patient is suffering with a current infection, the doctor prescribes treatment for it. This treatment is also considered treatment of granuloma present, though it is unlikely to remove the presence of starry liver.

Conditions such as sarcoidosis, autoimmune disease, Hodgkin lymphoma, or polymyalgia rheumatica may cause liver granuloma to form. Since most granuloma of the liver don’t trigger other liver symptoms, the doctor will seek the patient’s treatment of any of these serious underlying diseases as treatment for the granuloma.

Medicines taken for a chronic condition, such as some forms of tetracycline (used in acne treatment) or flagyl (used in treatment of bacteria and parasites) as well as non-steroidal anti-inflammatory drugs like ibuprofen are known to cause the growth and formation of granuloma. It’s important for anyone with concerns about liver and spleen health to let the doctor know about all medicines they’re taking.

Cancers of the liver may also present when granuloma are found. The National Cancer Institute says that too much iron, viral hepatitis, alcohol abuse, and liver cirrhosis are risk factors for the development of liver cancer. Since some liver cancers don’t present symptoms until the cancer is already advanced, high risk patients should be followed for early detection.

Liver Donor

Individuals who wish to donate a portion of their liver to someone in need of a transplant aren’t likely to be accepted if a granuloma is found during the evaluation process.


Many diseases, conditions, infections, or medicines can prompt the development of granulomas on the liver or spleen. If Dr. Cofrancesco doesn’t identify a current (active) infection or disease present, he is likely to conclude that a previous disease, condition, or medicine caused the liver to develop these spots. Presence of granuloma is always a reason for concern.

Patients with liver concerns or digestive disorders in search of patient-focused care should contact GI North today. The office is conveniently located in Johns Creek, and serves patients from Cumming, Canton, Alpharetta, Suwanee, Dawsonville, Canton, Roswell and the greater Atlanta metro area. Call Dr. Cofrancesco to arrange an appointment today at (404) 446-0600.

© 2014 GI North Gastroenterology Services. All rights reserved.

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