Hemobilia caused by a giant benign hemangioma of the liver: report of a case

Imaging features and management of focal liver lesions

Notably, the number of incidentally detected focal liver lesions (FLLs) has increased dramatically in recent years due to the increased use of radiological imaging. The diagnosis of FLLs can be made through a well-documented medical history, physical examination, laboratory tests, and appropriate imaging methods. Although benign FLLs are more common than malignant ones in adults, even in patients with primary malignancy, accurate diagnosis of incidental FLLs is of utmost clinical significance. In clinical practice, FLLs are frequently evaluated non-invasively using ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI). Although US is a cost-effective and widely used imaging method, its diagnostic specificity and sensitivity for FLL characterization are limited. FLLs are primarily characterized by obtaining enhancement patterns through dynamic contrast-enhanced CT and MRI. MRI is a problem-solving method with high specificity and sensitivity, commonly used for the evaluation of FLLs that cannot be characterized by US or CT. Recent technical advancements in MRI, along with the use of hepatobiliary-specific MRI contrast agents, have significantly improved the success of FLL characterization and reduced unnecessary biopsies. The American College of Radiology (ACR) appropriateness criteria are evidence-based recommendations intended to assist clinicians in selecting the optimal imaging or treatment option for their patients. ACR Appropriateness Criteria Liver Lesion-Initial Characterization guideline provides recommendations for the imaging methods that should be used for the characterization of incidentally detected FLLs in various clinical scenarios. The American College of Gastroenterology (ACG) Clinical Guideline offers evidence-based recommendations for both the diagnosis and management of FLL. American Association for the Study of Liver Diseases (AASLD) Practice Guidance provides an approach to the diagnosis and management of patients with hepatocellular carcinoma. In this article, FLLs are reviewed with a comprehensive analysis of ACR Appropriateness Criteria, ACG Clinical Guideline, AASLD Practice Guidance, and current medical literature from peer-reviewed journals. The article includes a discussion of imaging methods used for the assessment of FLL, current recommended imaging techniques, innovations in liver imaging, contrast agents, imaging features of common nonmetastatic benign and malignant FLL, as well as current management recommendations.

Surgery for symptomatic hepatic hemangioma: Resection vs. enucleation, an experience over two decades

Backgrounds/Aims

Hemangiomas are the most common benign liver lesions; however, they are usually asymptomatic and seldom require surgery. Enucleation and resection are the most commonly performed surgical procedures for symptomatic lesions. This study aims to compare the outcomes of these two surgical techniques.

Methods

A retrospective analysis of symptomatic hepatic hemangiomas (HH) operated upon between 2000 and 2021. Patients were categorized into the enucleation and resection groups. Demographic profile, intraoperative bleeding, and morbidity (Clavien-Dindo Grade) were compared. Independent t-test and chi-square tests were used for continuous and categorical variables respectively. p-value of < 0.05 was considered significant.

Results

Sixteen symptomatic HH patients aged 30 to 66 years underwent surgery (enucleation = 8, resection = 8) and majority were females (n = 10 [62.5%]). Fifteen patients presented with abdominal pain, and one patient had an interval increase in the size of the lesion from 9 to 12 cm. The size of hemangiomas varied from 6 to 23 cm. The median blood loss (enucleation: 350 vs. resection: 600 mL), operative time (enucleation: 5.8 vs. resection: 7.5 hours), and postoperative hospital stay (enucleation: 6.5 vs. resection: 11 days) were greater in the resection group (statistically insignificant). In the resection group, morbidity was significantly higher (62.6% vs. 12.5%, p = 0.05), including one mortality. All patients remained asymptomatic during the follow-up.

Conclusions

Enucleation was simpler with less morbidity as compared to resection in our series. However, considering the small number of patients, further studies are needed with comparable groups to confirm the superiority of enucleation over resection.

Endovascular treatment of a rare case of haemobilia caused by both pseudoaneurysm and a giant hepatic haemangioma

Haemobilia is defined as bleeding from the biliary system due to abnormal communication between a blood vessel and the bile ducts. Melena or hematemesis, abdominal pain and jaundice represent the pathognomonic triad for haemobilia, but clinical presentation and aetiology of this entity are extremely variable. We report a case of a 50-year-old man with melena and anaemia and a clinical history of multivalvular endocarditis in which an extremely rare presence of 2 uncommon causes of haemobilia was found, such as a mycotic pseudoaneurysm and a giant hepatic haemangioma, both treated by transarterial embolization. In the management of haemobilia, TAE has been proven to be the treatment of choice because it combines a diagnostic angiography with therapeutic intervention in a minimally invasive, safe and effective way. Physician and radiologist should keep in mind also the uncommon aetiologies of haemobilia, knowing that the source of bleeding could be more than just one.

Hepatic hemangioma: What internists need to know

Hepatic hemangioma (HH) is the most common benign liver tumor and it is usually found incidentally during radiological studies. This tumor arises from a vascular malformation; however, the pathophysiology has not been clearly elucidated. Symptoms usually correlate with the size and location of the tumor. Less commonly the presence of a large HH may cause life-threatening conditions. The diagnosis can be established by the identification of HH hallmarks in several imaging studies. In patients that present with abdominal symptoms other etiologies should be excluded first before attributing HH as the cause. In asymptomatic patient’s treatment is not required and follow up is usually reserved for HH of more than 5 cm. Symptomatic patients can be managed surgically or with other non-surgical modalities such as transcatheter arterial embolization or radiofrequency ablation. Enucleation surgery has shown to have fewer complications as compared to hepatectomy or other surgical techniques. Progression of the tumor is seen in less than 40%. Hormone stimulation may play a role in HH growth; however, there are no contraindications for hormonal therapy in patients with HH due to the lack of concrete evidence. When clinicians encounter this condition, they should discern between observation and surgical or non-surgical management based on the clinical presentation.

The risk of spontaneous rupture of liver hemangiomas: a critical review of the literature

BACKGROUND

The risk of spontaneous bleeding or rupture of liver hemangiomas still remains unknown. The aim of this review was to analyze the problem of spontaneous bleeding or rupture in liver hemangiomas and to identify factors leading to bleeding in these cases.

METHODS

A MEDLINE search was undertaken to identify articles in English, French, German, Italian, and Spanish from 1898 to 2010. Basic data such as age and sex of patients were collected. Additional data such as risk factors or causes of rupture were also analyzed. Cases were divided into spontaneous and non-spontaneous ruptures.

RESULTS

A total of 97 cases are described. In 51 of the 97 patients (52.6%) a non-spontaneous rupture was identified. Only in 46 out of the 97 cases (47.4%) was a spontaneous rupture found. Non-spontaneous rupture was significantly more frequent in patients aged <40 years than in older ones (p = 0.0099). Mean size of the ruptured lesions was 11.2 cm (range 1-37 cm). Massive bleeding occurred in 88 patients (90.7%). Reported mortality over the past 20 years has been significantly lower than before (p < 0.001). The overall mortality for the period under study was ~35%.

CONCLUSIONS

The spontaneous rupture of a hepatic hemangioma is to be considered an exceptional event. Preventive surgery should be considered only for lesions of at least 11-cm size in special cohorts of patients.

Review article: the evaluation of solitary liver masses

BACKGROUND

The increasing use of imaging modalities has led to the detection of more liver masses. The differential diagnosis of a focal liver mass includes a host of benign as well as malignant conditions.

AIM

To provide a comprehensive review on the commonly encountered liver masses, and to help guide an approach to their evaluation and management.

METHODS

Pertinent literature that was identified through PubMed search and senior author's experience formed the basis of this review.

RESULTS

While most incidentally noted liver masses are benign, it may be difficult to differentiate them from those that are malignant. Furthermore, some benign lesions have malignant potential. Certain lesions such as focal nodular hyperplasia, haemangiomas and focal steatosis are often distinctly diagnosed by an imaging modality alone. The less frequently encountered hepatic adenomas are diagnosed radiologically in those with the appropriate clinical background and the absence of radiological features to suggest haemangioma or focal nodular hyperplasia.

CONCLUSIONS

A reasonable approach to the diagnosis, follow-up and management of liver masses is based on a rudimentary knowledge of their presentation, associated clinical and laboratory features, natural history and available treatment options. Most often, the so called 'incidentalomas' are benign and require patient reassurance.

Haemobilia

BACKGROUND

This review aims to establish whether increased use of invasive procedures and the trend toward conservative management of major trauma has resulted in an increased incidence of haemobilia.

METHOD

A Medline (http://igm.nlm.nih.gov/)-based search of the English language literature from January 1996 to December 1999 inclusive was performed using the keywords haemobilia, hemobilia, haematobilia and hematobilia. The presentation, aetiology, investigation, management and outcome of 222 cases were reviewed.

RESULTS

Two-thirds of cases were iatrogenic while accidental trauma accounted for 5 per cent. Haemobilia may be major, constituting life-threatening haemorrhage, or minor; it may present many weeks after the initial injury. Diagnosis is most commonly confirmed by angiography. Management is aimed at stopping bleeding and relieving biliary obstruction; 43 per cent of cases were managed conservatively and 36 per cent were managed by transarterial embolization (TAE). Surgery was indicated when laparotomy was performed for other reasons and for failed TAE. The mortality rate was 5 per cent.

CONCLUSIONS

Although the incidence of iatrogenic haemobilia has risen considerably, the bleeding is often minor and can be managed conservatively. When more urgent intervention is required, TAE is usually the treatment of choice. There is no evidence that the conservative management of accidental liver trauma increases the risk of haemobilia.