eMedicine Specialties > Radiology > Gastrointestinal

Cavernous Hemangioma, Liver

Author: Srinivasa Prasad, MD, Associate Professor, Department of Radiology, Division of Abdominal Imaging and Intervention, University of Texas Health Science Center at San Antonio
Coauthor(s): Dushyant Sahani, MD, Clinical Instructor of Abdominal Radiology and Intervention, Harvard Medical School; Assistant Radiologist, Department of Abdominal Imaging and Intervention, Massachusetts General Hospital; Sanjay Saini, MD, Associate Professor, Department of Radiology, Harvard Medical School; Vice Chairman, Department of Radiology, Health System Affairs, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Aug 29, 2007

Introduction

Background

Cavernous hemangioma is the most common primary liver tumor; its occurrence in the general population ranges from 0.4-20%, as reported by Karhunen in an autopsy series.1 Cavernous hemangiomas arise from the endothelial cells that line the blood vessels and consist of multiple, large vascular channels lined by a single layer of endothelial cells and supported by collagenous walls. These tumors are frequently asymptomatic and incidentally discovered at imaging, surgery, or autopsy. Hemangiomas are uncommon in cirrhotic livers; the fibrotic process in cirrhotic liver may prohibit their development.2

Usually, cavernous hemangiomas occur as solitary lesions; however, they may be multiple in as many as 50% of patients.3 No lobar predilection exists, and the tumors may be associated with focal nodular hyperplasia.4 Hemangiomas typically measure less than 5 cm; those larger than 4-5 cm are sometimes called giant hemangiomas.5,6

Pathophysiology

The natural history of liver hemangioma is not completely understood. Hemangiomas are probably congenital in origin, and hereditary factors may play a role in the pathogenesis of some familial forms of these tumors. Although the growth of hemangiomas is reported in the literature, ectasia is believed to contribute to lesion enlargement.7 Moreover, according to the findings in a study by Brancatelli et al, hemangiomas may become fibrotic and shrink in patients with progressive cirrhosis, leading to more difficulty with radiologic and pathologic diagnoses.8

Sex

A distinct female preponderance has been reported in surgical series, with a female-to-male ratio ranging from 5:1 to 6:1. However, in children and in autopsy series, cavernous hemangioma of the liver affects males and females equally .

Age

Hemangiomas can occur in individuals of any age. The tumors frequently occur in middle-aged women.

Presentation

The vast majority of hemangiomas (as many as 85%) are asymptomatic; however, hemangiomas may cause symptoms because of the compression of adjacent structures, rupture, acute thrombosis, or consumptive coagulopathy (ie, Kasabach-Merritt syndrome).

Pressure on the stomach and duodenum caused by large pedunculated hemangioma lesions may cause vague abdominal pain, early satiety, nausea, and vomiting. Pedunculated hemangiomas may twist and cause acute abdominal pain.9 Compression of the inferior vena cava may result in Budd-Chiari syndrome.10 Acute thrombosis may result in acute inflammatory changes that cause fever, abdominal pain, and abnormal results in liver function tests.11 Spontaneous or posttraumatic rupture is a catastrophic complication that occurs in about 1-4% of hemangiomas; this condition has a considerable mortality rate, as high as 60%.6

Preferred Examination

Most patients with liver hemangioma are asymptomatic. Clinical findings usually do not contribute to the diagnosis. Laboratory test results may suggest anemia, and reduced hematocrit levels may be present in patients who have ruptured hemangiomas. In patients who have giant hemangiomas that are associated with Kasabach-Merritt syndrome, bleeding and clotting laboratory parameters may be abnormal.

Most hemangiomas are incidentally detected on imaging studies. Ultrasonography is a cost-effective imaging modality for the diagnosis of a hemangioma. However, computed tomography (CT) scanning and/or MRI may be required to specifically diagnose a hemangioma.

Limitations of Techniques

Ultrasonography is a heavily operator-dependent technique; its performance depends on the expertise and experience of the ultrasonographer. In addition, the acquisition of satisfactory images in obese patients is technically difficult. Contrast-enhanced CT scanning is relatively contraindicated in patients who have renal insufficiency and in those who have a previous history of hypersensitivity to iodinated contrast agents; thus, MRI may be the preferred modality of choice in the characterization of hemangiomas in such patients. Angiography is an invasive method that is used for the characterization of liver hemangiomas; this imaging modality is associated with low but definite risks of morbidity and mortality.

Differential Diagnoses

Focal Nodular Hyperplasia
Hepatocellular Carcinoma
Liver, Metastases

Other Problems to Be Considered

Hepatoma
Adenoma
Hypervascular metastases

More on Cavernous Hemangioma, Liver

Overview: Cavernous Hemangioma, Liver
Imaging: Cavernous Hemangioma, Liver
Follow-up: Cavernous Hemangioma, Liver
Multimedia: Cavernous Hemangioma, Liver
References
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References

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Further Reading

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Keywords

hepatic cavernous hemangioma, hepatic hemangioma, hemangioma of the liver, giant hemangioma of the liver, primary liver tumor, focal nodular hyperplasia, Kasabach-Merritt syndrome

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Contributor Information and Disclosures

Author

Srinivasa Prasad, MD, Associate Professor, Department of Radiology, Division of Abdominal Imaging and Intervention, University of Texas Health Science Center at San Antonio
Srinivasa Prasad, MD is a member of the following medical societies: American Roentgen Ray Society, Radiological Society of North America, and Society of Uroradiology
Disclosure: Nothing to disclose.

Coauthor(s)

Dushyant Sahani, MD, Clinical Instructor of Abdominal Radiology and Intervention, Harvard Medical School; Assistant Radiologist, Department of Abdominal Imaging and Intervention, Massachusetts General Hospital
Disclosure: Nothing to disclose.

Sanjay Saini, MD, Associate Professor, Department of Radiology, Harvard Medical School; Vice Chairman, Department of Radiology, Health System Affairs, Massachusetts General Hospital
Sanjay Saini, MD is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, New England Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Udo P Schmiedl, MD, PhD, Clinical Professor, Department of Radiology, University of Washington; Consulting Staff, Swedish Medical Center, University of Washington Medical Center, Seattle Radiologists
Udo P Schmiedl, MD, PhD is a member of the following medical societies: American College of Radiology and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Consulting Staff, Department of Radiology, King's College Hospital, London
Disclosure: Nothing to disclose.

 
 
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