Giant Hepatic Hemangioma with Bleed: A Rare Presentation!

A 37-year-old male presented with the right upper quadrant discomfort and pain for 6 weeks. On examination, the patient was pale and tender liver was palpable 5 cm below the right costal margin. Blood investigations showed hemoglobin 8.8 g/dL, total counts of 8600/dL with normal differential count, and platelets 1.09 lakhs/dL. Liver biochemistry showed bilirubin 2.14 mg/dL, aspartate transaminase 60, alanine transaminase 32, and serum albumin of 3.3 g/dL. Ultrasound abdomen showed a large heterogeneous lesion in the right lobe of the liver suggestive of an abscess. Contrast-enhanced computed tomography (CT) abdomen showed an enlarged liver with multiple heterogeneous lesions (atypical hemangiomas) largest of which was 14.8 cm × 12.7 cm × 15.5 cm in the right lobe of the liver with internal high attenuation regions on noncontrast CT indicating acute hemorrhage. Contrast-enhanced films showed hyperdense areas in the arterial phase indicating active bleed into the largest lesion [Figure 1]. Superselective embolization of the right hepatic artery controlled the bleed [Figure 2]. In view of the multiple dispersed lesions, surgical resection was not intended. The patient was advised for liver transplantation and was subsequently lost to follow-up.Figure 1: (a) Noncontrast and (b) contrast-enhanced computed tomography images showing a large hemangioma with acute bleedFigure 2: (a) Superselective cannulation and (b) embolization controlled the bleedHepatic hemangioma can be diagnosed at any age; however, the majority of lesions (60%–80%) are diagnosed in patients who are between the ages of 30 and 50 years. In adults, hemangiomas occur more frequently in women with a ratio of approximately 3:1. Hemangiomas more than 5 cm in size are called as giant hemangiomas. They may be asymptomatic or may present with right upper quadrant pain or fullness.[1] Rarely, acute abdominal pain can result due to thrombosis or bleeding from the lesion that results in stretching and inflammation of the Glisson’s capsule. Abdominal pain from an acute thrombosis may be associated with fever and abnormal liver biochemical tests. Hemangiomas >10 cm may require surgical intervention.[2] A variety of imaging patterns may be noted on CT scan.[3] Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.