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Liver hemangiomas are one of the most common benign liver tumors. Most of them are asymptomatic and are accidentally detected during an ultrasound of the abdominal cavity. Liver hemangiomas occur with the same frequency in both sexes, with a prevalence of 5-10% in the general population. Their etiopathogenesis has not been fully elucidated.
Liver hemangiomasequally occupy the left and right lobes of the liver and can vary in size. Their diameter ranges from a few millimeters to even a few or a dozen centimeters.
Changes with a diameter greater than 5 cm are called giant hemangiomas.
Larger hemangiomas are more often observed in women - especially in those who use hormonal contraceptives and in pregnancy.
Liver hemangioma: symptoms
Due to the fact that most hemangiomas are small, they do not cause any problems. Clinical symptoms appear only in patients with large hemangiomas.
You may feel pain and discomfort in the right hypochondrium, which results from the stretching of the liver capsule, pressure on the adjacent abdominal organs, as well as twisting the pedunculated hemangioma.
Pain may also result from thrombotic changes in the hemangioma, as well as from the rapid enlargement of the lesion, which results in the stretching of the liver capsule.
It is assumed that the perceived pain and low-grade fever in some patients may be the result of retrograde changes in the hemangioma, which include calcifications and focal necroses.
It is worth knowing that a serious, but rare complication is angioma rupture. If present, it concerns large lesions with a diameter exceeding 10 cm and usually requires surgical treatment.
It can very rarely be accompanied by the so-called Kasabach-Merrit syndrome, which includes thrombocytopenia and consumption coagulopathy.
Liver hemangioma: diagnosis
Imaging tests play a major role in the diagnosis of hepatic hemangiomas - abdominal ultrasound, computed tomography, magnetic resonance imaging and scintigraphy.
Fine needle aspiration biopsy (FNAB) of the lesion is very rarely performed due to the high risk of bleeding and the low usefulness of the obtainedcell material for microscopic examination - the material collected at that time contains mainly morphotic elements of blood.
In the ultrasound image, small hemangiomas (up to 5 cm in diameter) are visible as oval, hyperechoic and well demarcated from the surrounding parenchyma, while the larger ones have a heterogeneous echostructure.
The use of Doppler ultrasound is of little diagnostic importance, as the blood flow in the hemangioma is very slow - no signal is found in this situation.
Another diagnostic method is abdominal computed tomography (CT) using contrast. It is used not only to diagnose hepatic hemangioma, but also to determine indications for possible surgical treatment.
A characteristic feature of the CT scan is a slow inflow of blood from the periphery of the lesion to its center. Before the intravenous administration of the contrast material, it is visualized as an oval, well-delimited, structurally uniform and hypodense lesion.
It is worth remembering that small hemangiomas and massive thrombosis within the hemangioma are difficult to assess in computed tomography - it will not saturate with the contrast agent then.
Magnetic resonance imaging (MRI) with the administration of a contrast agent is used in particularly doubtful cases. It is worth remembering that the sensitivity of this examination is greater than that of ultrasonography.
The last diagnostic test used is technetium (99Tc) -labeled red blood cells, which is the most specific. It enables the visualization of technetium-labeled red blood cells accumulated in the hemangioma.
Liver hemangioma: treatment
Small hemangiomas of the liver, not exceeding 5 cm in diameter, not enlarging and not threatening to rupture, require only regular observation (every 6-12 months) and ultrasound evaluation.
If there is a lesion larger than 5 cm in diameter, it is worth checking the coagulation system additionally.
In patients with hemangiomas larger than 10 cm in diameter and with clinical symptoms (fever, pain, signs of coagulopathy), surgical treatment should be considered.
The indications for surgical treatment include rupture of the hemangioma, compression of the hemangioma on adjacent organs, rapidly enlarging lesions, and the presence of an arteriovenous fistula.
It is worth mentioning here that hemangiomas detected during surgery for any other reason are removed only when there is a high risk of rupture, i.e. when they have a tight bag or when they are superficially located.
Additionally, in patients who have had their liver resected for technical reasonsimpossible or contraindicated, treatment with the use of interventional radiology may be used.