S5691 Ouch! What’s That Pain in My Gut? An Atypical Presentation of a Hepatic Hemangioma

Introduction: Hepatic hemangiomas (HH) are common benign liver neoplasms, occurring in up to 20% of the population.1 They are usually asymptomatic and incidentally found on imaging. Large HHs (>5 cm) are uncommon, while giant HHs (≥10 cm) are rare. We present a case of a giant HH presenting with acute abdominal pain and mixed type hepatic injury. Symptomatic lesions raise concern for rupture, intramural hemorrhage, or compression, thus emphasizing the need for swift diagnosis. Case Description/Methods: A 42-year-old woman with prior cholecystectomy presented with one week of right upper quadrant abdominal pain radiating to the back and nausea. She denied alarm symptoms, oral contraceptive use, or personal or family history of gastrointestinal malignancy or liver disease. Labs showed normal blood counts, transaminitis to the 140s, and alkaline phosphatase of 278 IU/L. Exam showed diffuse abdominal tenderness without peritoneal signs. A computed tomography scan of abdomen/pelvis with contrast showed an 11 cm hepatic lesion in the left lobe. The lesion, reported as a HH, demonstrated peripheral nodular contrast retention with central necrosis. Surgical resection was recommended for ongoing pain, and an uncomplicated partial left hepatectomy was performed. Pathology showed an ill-defined 10 cm hemorrhagic vascular mass with central vascular tissue. Final diagnosis was giant HH without malignancy. Her postoperative course was uneventful with improved liver enzymes and pain before discharge the next day. Discussion: HHs are typically asymptomatic, less than 5 cm in size, and require no intervention beyond observation. In contrast, giant HHs can reach sizes up to 20-30 cm, have a higher likelihood of becoming symptomatic, and may cause severe complications associated with high mortality rates (36-39%).2 In general, HHs are diagnosed based on imaging characteristics alone. No further follow up imaging is needed, except for those at risk of hepatocellular carcinoma since early malignant lesions can mimic HH.1 Surgical resection is the definitive treatment for symptomatic lesions to manage symptoms and avoid serious outcomes. References 1. Frenette C, Mendiratta-Lala M, Salgia R, Wong RJ, Sauer BG, Pillai A. ACG Clinical Guideline: Focal Liver Lesions. Am J Gastroenterol. 2024;119(7):1235-1271. 2. Hoekstra LT, Bieze M, Erdogan D, Roelofs JJ, Beuers UH, van Gulik TM. Management of giant liver hemangiomas: An update. Expert Rev Gastroenterol Hepatol. 2013;7(3):263-268.