Marrero JA, Ahn J, Rajender Reddy K, American College of Gastroenterology. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol. 2014 Sep;109(9):1328-47; quiz 1348. doi: 10.1038/ajg.2014.213. Epub 2014 Aug 19. PMID: 25135008.
CLINICAL Features AND NATURAL HistoryTop
Liver hemangioma is the most common benign neoplasm of the liver (it occurs in 2%-5% of the population and is several times more frequent in women). It usually manifests as a single focal lesion, rarely as multiple lesions. Most often it has no symptoms and is found incidentally on imaging. If present, most common symptoms include vague right upper quadrant discomfort, fullness, and early satiety. Rarely, in the case of large hemangiomas, thrombosis (associated with acute abdominal pain and fever) as well as Kasabach–Merritt syndrome (thrombocytopenia and consumption coagulopathy due to clot development in the hemangioma) may occur. Also, symptoms related to the tumor pressing on adjacent organs may sometimes be present, such as early satiety and abdominal pain. Very rare complications of hemangiomas include intraperitoneal rupture and consumption coagulopathy.
1) Ultrasonography and computed tomography (CT): see Table 7.3-1.
2) Magnetic resonance imaging (MRI): In ambiguous cases, it may be used complementary to ultrasonography and a CT scan.
3) Technetium (99mTc)-labeled red blood cell scintigraphy has the highest specificity, but due to the high cost, it is rarely performed for this indication.
In the case of lesions <3 cm in diameter and a typical ultrasound image (see Table 7.3-1) found in a person without liver disease, ultrasonography is sufficient to establish the diagnosis. If the lesion is larger or it is found in a person with liver disease or a malignant tumor, then contrast-enhanced ultrasonography, CT, or MRI is required to confirm the diagnosis. A suspicion of hemangioma is a contraindication to lesion biopsy given the low diagnostic yield and bleeding risk.
Focal lesions in the liver: Focal nodular hyperplasia, adenoma, cysts, hepatocellular carcinoma, metastatic cancer, cancer of the intrahepatic bile ducts.
1. The vast majority of hepatic hemangiomas do not require treatment. Perform ultrasonography periodically, every 12 months (more often in the case of enlarging lesions).
2. Indications for surgical treatment: Lesions >10 cm in diameter, clinical symptoms (pain [acute pain in a patient with a large hemangioma may be a symptom of an impending tumor rupture], fever), significant diagnostic uncertainty, rapid enlargement of the hemangioma, consumption coagulopathy, vascular anomalies (arteriovenous shunt causing diversion of blood flow), compression of the bile ducts or adjacent organs.
3. When surgical treatment is impossible, embolization of the artery supplying the hemangioma may be attempted.
Liver hemangiomas are no contraindication to the use of combined oral contraceptive pills or to pregnancy. In large cavernous hemangiomas (defined variably, 5 or 10 cm in diameter) the increase in intra-abdominal pressure and blood volume during pregnancy may increase the risk of rupture (but the risk still remains low).
Regardless of their size, hemangiomas do not require surveillance during pregnancy. Testing is necessary when new symptoms develop.