Spontaneous rupture of a giant hepatic hemangioma - sequential management with transcatheter arterial embolization and resection

Abstract

Hemangioma is the most common benign tumor of liver and is often asymptomatic. Spontaneous rupture is rare but has a catastrophic outcome if not promptly managed. Emergent hepatic resection has been the treatment of choice but has high operative mortality. Preoperative transcatheter arterial embolization (TAE) can significantly improve outcome in such patients. We report a case of spontaneous rupture of giant hepatic hemangioma that presented with abdominal pain and shock due to hemoperitoneum. Patient was successfully managed by TAE, followed by tumor resection. TAE is an effective procedure in symptomatic hemangiomas, and should be considered in such high risk patients prior to surgery.

Spontaneous internal hemorrhage of a giant hepatic hemangioma

“…If not promptly and appropriately managed, all the above complications are associated with increased risk of mortality. [ 8 , 16 , 17 ] Reports on hepatic hemangioma with internal hemorrhage are rather rare; only a few are available worldwide. [ 18 – 20 ] In general, the ultrasound manifestations of hemangiomas are slightly enhanced echoes and have relatively clear demarcation unless complicated with hemorrhage, fibrosis, or calcification when hypoechoic changes are observed.…”

“…[ 22 ] It is reported that the operative mortality rate of a ruptured hemangioma is about 36.5%. [ 8 ] For hemangiomas with spontaneously ruptured bleeding, interventional therapies are reported to achieve auxiliary or ideal therapeutic effects [ 10 , 23 ] ; therefore, we first adopted interventional approaches and found that the right phrenic artery was the blood supply vessel of the hemangioma. This condition, never seen in any previous literature, might share the same underlying pathogenesis of the hepatic carcinoma in which the huge and fast-growing tumor opens and dilates the collaterals between the phrenic and hepatic arteries.…”

“…Surgical treatment is the predominant therapeutic approach for a hepatic hemangioma with ruptured bleeding [ 7 ] but there are certain risks involved. [ 8 ] Recently, it was reported that interventional embolization can improve or even control hepatic hemangioma with ruptured bleeding, which may avoid or prepare for further surgical treatment [ 9 ] ; however, the therapeutic efficacy is still unclear. [ 10 ] In the current report, we describe the findings and management approaches in a female patient with a giant liver space occupying lesion (SOL), confirmed as internal hemorrhage of the lesion via liver needle biopsy.…”

Rupture of hepatic hemangioma with hemoperitoneum due to spontaneous gallbladder perforation

“…Although rare, it is associated with a high mortality rate. [ 7 ] Jain et al [ 8 ] reported a mortality rate ranging from 60% to 75% for spontaneous rupture with an operative mortality rate of 36.4%. Patients can die of massive hemorrhage in a short period of time.…”

“…[ 16 ] However, the use of TAE as an alternative to surgery in the management of ruptured HHs remains controversial. [ 8 , 14 , 16 ] If the patient is stable, TAE prior to surgery may decrease intraoperative blood loss. [ 2 ] In hemodynamically unstable patients with spontaneous rupture of HH, operative treatment is the preferred choice.…”