WeBSurg, the e-surgical reference of Laparoscopic surgery

Clinical Case

RUPTURED HEPATIC ANGIOMA

D Mutter, MD, PhD, M Smith, MD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Summary

This clinical case reports the rupture of a large hepatic angioma. The emergency treatment is ideally radiologic by embolization. The follow-up treatment of a hepatectomy will be discussed as a function of the size of the lesion and the general state of health of the patient.

2. Patient

75-year-old woman

3. Past medical history

Medical:
- HTN for 2 years;
- atrial flutter treated with anticoagulation;
- treatment: Sotaloc, Fluindione.

Surgical:
- appendectomy 30 years ago

4. History of present illness

The patient is a 75-year-old woman. During a hospital stay for regulation of hypertension, she develops generalized malaise, abdominal pain and right shoulder pain.
The Hgb is noted to drop from 12,3 g/l to 7,6 g/l.

5. Examinations

5.1. Physical examination

Diffuse abdominal guarding. Patient is in a fetal position.

5.2. Ultrasonography

Right upper quadrant mass with active bleeding

Figure 5.2.a

Figure 5.2.b

5.3. CT scan

Confirms the presence of a heterogeneous mass in the right lobe of the liver with an intrahepatic hematoma and hemoperitoneum.

Figure 5.3.a

Figure 5.3.b

5.4. Evaluation and workup

During this hemorrhage of the right liver most probably from a hemangioma, different therapeutic options are considered:

1. Observation
2. Emergency operation
3. Emergency angiography with embolization of the bleeding vessel

6. Arteriography

This patient underwent an arteriography with embolization. No active bleeding is identified. Right hepatic artery embolization is performed in order to continue the anticoagulation of the patient for the atrial flutter.

Figure 6.a

Figure 6.b

7. Clinical course

The bleeding stops.
Marked elevation of hepatic enzymes (AST, ALT x 500)
These normalize over the next 10 days.
Follow-up CT scan shows right hepatic lobe infarction with no reperfusion.

Figure 7.a

Figure 7.b

8. Quizzes

8.1. Quiz 1

What are the 3 most common tumors of the liver?
1) Liver metastases from a primary cancer
2) Primary liver cancer: hepatocellular carcinoma
3) Hepatic adenomas
4) Focal nodular hyperplasia
5) Hepatic hemangioma
Correct answers:
1) Liver metastases from a primary cancer
3) Hepatic adenomas
5) Hepatic hemangioma
The liver metastases from cancer represent the most common cause of malignant liver tumors. The relative proportion of primary liver cancer compared to metastatic tumors of the liver is estimated at 1 to 20, in the western world. This pathology is less common in the western societies, although its incidence is high in Asia and in Africa. Hepatitis B and C leading to cirrhosis are the main etiologic factors. The incidence of hepatic adenomas has increased since the introduction of the contraception pill in the 1960s. These lesions occur most frequently in females. This lesion is benign and has no risk of malignancy. It occurs twice as often in women than in men. The liver hemangioma is the most common nodule in the liver. It occurs five times more often in women than in men. The hepatic sarcoma is an extremely rare tumor and by the time it is diagnosed it has often already metastasized. The angiomyolipoma is a benign tumor of mesenchymal origin often found in the kidney. Its incidence is low (0.07 to 0.3% in the general population).

8.2. Quiz 2

In reference to hepatic hemangiomas, which answer(s) is/are correct?
1) They have a typical appearance on ultrasound.
2) They are easily diagnosed with a CT scan without contrast.
3) It is best diagnosed by MRI.
4) Angiography is the ideal diagnostic method.
Correct answer:
3) It is best diagnosed by MRI.
The ultrasound appearance of hemangiomas varies according to their type and can appear as a benign or malignant liver tumor. A routine CT scan does not allow a precise diagnosis of hemangioma. Injection of contrast dye during different sequences of the scan demonstrates an accumulation of contrast in the periphery of the lesion towards the center, which is characteristic of a cavernous hemangioma. The MRI is very sensitive for the diagnosis of hepatic hemangiomas. The T2-weighted scans with a value greater than 80 allow a precise diagnosis of a hemangioma. When nuclear imaging is performed, the ideal agent for identifying the hemangioma of the liver is Tc99. While angiography can be useful to establish the diagnosis, it is an invasive exam and is rarely indicated to obtain a diagnosis.

9. Discussion

Approximately 2% of livers at autopsy contain cavernous hemangiomas, making this the most common liver tumor encountered coincidentally at laparotomy. Most hemangiomas are small and do not cause symptoms. Surgical therapy is indicated for symptomatic or enlarging hemangiomas. Symptoms (abdominal pain and fullness) are mostly seen in giant lesions. Spontaneous rupture is unusual but can be dramatic as illustrated in this case. Approximately 30 cases of spontaneous ruptures of hepatic hemangiomas have been described in the literature and emergent operative therapy is usually associated with a high mortality rate (in excess of 60%). The main question that remains to be answered in this case is how to manage the patient now that she has been successfully embolized. There is little data in the literature to support any approach (operation versus observation). Surgical intervention may be indicated for complications of hepatic necrosis following the embolization.

10. References

Cappellani A, Zanghi A, Di Vita M et al. Spontaneous rupture of a giant hemangioma of the liver. Ann Ital Chir 2000;71:379-83.
Panis Y, Fagniez PL, Cherqui D et al. Successful arterial embolisation of giant liver haemangioma. Report of a case with five-year computed tomography follow-up. HPB Surg 1993;7:141-6.
Yamamoto T, Kawarada Y, Yano T et al. Spontaneous rupture of hemangioma of the liver: treatment with transcatheter hepatic arterial embolization. Am J Gastroenterol 1991;86:1645-9.

Username
Password
	Remember me (needs cookies)