Haemangioma is a benign (non-cancerous) vascular lesion which is formed from a collection of small blood vessels. Similarly, hepatic hemangiomas or also known as cavernous liver haemangiomas, are non-cancerous - benign tumours of the liver. They consist of malformed clusters of blood-filled cavities lined by endothelial cells and fed by the hepatic artery.1 The majority of hepatic haemangiomas are asymptomatic and usually discovered accidentally. Generally, the capillary size in hemangiomas]’ ranges from a few mm to 3 cm, and it’s not increasing in size over time. In most cases, hepatic haemangioma lesions are either small (< 3 cm) or medium (3 cm-10 cm). However, on rare occasions, a larger form which is called giant liver hemangioma, may occur. Its size may range from 10 cm up to more than 20 cm, and accordingly, it may develop symptoms and complications that require urgent surgical intervention or adjunctive therapies. It can be diagnosed at any age, starting from early birth. However, it is most commonly found in persons with ages ranging from 30-50 years.
Causes of liver hemangioma
The main causative agents that contribute to developing liver haemangiomas are still unknown. Some studies suggest that it is usually present earlier in life as a birth anomaly due to genetic disorders. This condition is known as infantile hepatic hemangioma.2 However, this condition is usually fatal and can be life-threatening. In addition, it was found that the hormones are related to the increase in symptoms of hepatic haemangioma. For instance, females who are pregnant or use estrogen therapy, oral contraceptives, or even replacement therapy to reduce menopause symptoms are at a higher risk of developing liver haemangiomas.3
Signs and symptoms of liver hemangioma
Generally, there are no definitive signs and symptoms for liver hemangioma, especially those of small size (up to 10 cm). However, in some cases, symptoms may arise in relation to an enlarged condition which is, called giant liver hemangiomas. Those symptoms may include:
- Abdominal pain (in the upper right quadrant)
- Bloating of stomach4
Management and treatment for liver hemangioma
Small lesions (non-surgical): Most liver hemangiomas are small and asymptomatic at the time of diagnosis. Therefore, they do not require any intervention as long as they are not causing any complications or pain. In such cases, a periodic follow-up (ideally twice a year) using imaging aids is important to track any progress in terms of increased size that can lead to further complications. Some studies suggested the use of anti-angiogenic therapy with bevacizumab to eliminate the endothelial growth factor activity and thus decrease the risk of growth of the haemangioma.5,6
Large lesions (surgical): Large liver hemangiomas are characterised by a rapid increase in the size of the lesion and mainly depends on the size and location of the lesion. Surgical modalities may include:
- Surgical resections or enucleation: Remove your liver hemangioma or part of your liver, including the hemangioma either by open surgery or laparoscopy7,8
- Liver transplantation: Remove your liver and replace it with a liver from a donor. Liver transplantation is recommended in severe cases such as giant liver haemangioma9
On the other hand, there are other treatment modalities available such as
- Radiofrequency ablation: Which Uses heat-generating electrical current to treat chronic pain10
- Radiation therapy: Which uses X-ray beams to disrupt the haemangioma cells, but it is not adequately safe11
Diagnosis of liver hemangioma
Most hepatic haemangiomas are diagnosed accidentally during an imaging test. The most commonly used reliable methods of diagnostic imaging include:
- Conventional ultrasound (US, B-mode and Doppler)12
- Contrast-enhanced ultrasound (CEUS)13
- Contrast-enhanced computed tomography (CT),14
- Magnetic resonance imaging (MRI)15
- Technetium-99m labelled Red Blood Cell scintigraphy which is a nuclear scan used to differentiate between hepatic haemangioma and other vascular tumours, benign tumours or malignant ones16
Medications such as steroids, can accelerate the development of an existing hepatic haemangioma.
Female pregnancies and hormonal therapies can increase the risk of complications of hepatic haemangiomas by increasing their size. For instance, estrogen therapy, oral contraceptives, and therapies reducing menopausal symptoms as well as pregnancy may disrupt the estrogen and progesterone hormone levels. This lead to an increase in the size of liver haemangiomas.
The complications are mainly depending on the size of the haemangiomas. Long-standing haemangiomas may lead to:
- Compressing some nearby structures, which may lead to severe complications. For instance, compression of the blood vessels leads to a block of hepatic veins. This blockage causes blood to back up into the liver, and as a result, the liver grows larger. This condition is known as Budd-Chiari syndrome17
How can I prevent liver hemangioma?
Generally, there are no recommendations to prevent liver haemangioma as long as the causative agent is still unknown. However, if you have a liver haemangioma, you can reduce the risk of its growth by avoiding hormonal therapy.
In addition, following a proper healthy diet full of fibre with less saturated fats and refined sugars can be beneficial.
How common is liver hemangioma?
It is considered one of the most prevalent benign liver tumours. It affects about 0.4%-20% of the population, while it is most commonly found in females ( 0.4%-7.3% prevalence ranges).1
When should I see a doctor?
Liver haemangiomas are usually discovered by chance during a routine check-up. Therefore, it is always advised to visit your nearest clinic for periodic check-ups, especially if you suffer any sort of discomfort related to the digestive system, such as abdominal pain. This will allow early diagnosis and prevent any related complications. The general doctor will directly refer suspected patients for further investigations by gastroenterologists (a specialist in gastrointestinal diseases).
You should not worry if you discover that you have liver haemangioma, as in most cases, it doesn’t require any treatment. However, it should be emphasised that periodic check-ups are of great importance even if you are not suffering any diseases. It will protect you against any complications that may arise suddenly. Thus, it is advised to visit your general doctor twice yearly.
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- Zavras N, Dimopoulou A, Machairas N, Paspala A, Vaos G. Infantile hepatic hemangioma: current state of the art, controversies, and perspectives. Eur J Pediatr [Internet]. 2020 Jan [cited 2023 Jul 31];179(1):1–8. Available from: https://pubmed.ncbi.nlm.nih.gov/31758313/
- Gong X, Li Y, Yang K, Chen S, Ji Y. Infantile hepatic hemangiomas: looking backwards and forwards. Precis Clin Med [Internet]. 2022 Mar [cited 2023 Jul 31];5(1). Available from: https://academic.oup.com/pcm/article/5/1/pbac006/6526892
- Ayoobi Yazdi N, Dashti H, Batavani N, Borhani A, Shakiba M, Rokni Yazdi H. Percutaneous sclerotherapy for giant symptomatic liver hemangiomas: a pilot study. Journal of Vascular and Interventional Radiology [Internet]. 2018 Feb 1 [cited 2023 Jul 31];29(2):233–6. Available from: https://www.sciencedirect.com/science/article/pii/S1051044317309211
- Lopes-Coelho F, Martins F, Pereira SA, Serpa J. Anti-angiogenic therapy: current challenges and future perspectives. Int J Mol Sci [Internet]. 2021 Apr 5 [cited 2023 Jul 31];22(7):3765. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8038573/
- Liu T, Pan W, Lai S, Luo J. Can angiogenesis inhibitor therapy cause changes in imaging features of hepatic hemangioma- Initial study. Frontiers in Oncology [Internet]. 2023 [cited 2023 Jul 31];13. Available from: https://www.frontiersin.org/articles/10.3389/fonc.2023.1134179
- Aziz H, Brown ZJ, Baghdadi A, Kamel IR, Pawlik TM. A comprehensive review of hepatic hemangioma management. J Gastrointest Surg [Internet]. 2022 Sep [cited 2023 Jul 31];26(9):1998–2007. Available from: https://pubmed.ncbi.nlm.nih.gov/35705835/
- Ju M, Xu F, Zhao W, Dai C. Efficacy and factors affecting the choice of enucleation and liver resection for giant hemangioma: a retrospective propensity score-matched study. BMC Surg [Internet]. 2020 Nov 7 [cited 2023 Jul 31];20(1):271. Available from: https://doi.org/10.1186/s12893-020-00935-0
- Prodromidou A, Machairas N, Garoufalia Z, Kostakis ID, Tsaparas P, Paspala A, et al. Liver transplantation for giant hepatic hemangioma: a systematic review. Transplantation Proceedings [Internet]. 2019 Mar 1 [cited 2023 Jul 31];51(2):440–2. Available from: https://www.sciencedirect.com/science/article/pii/S0041134519300260
- Kong J, Gao R, Wu S, Shi Y, Yin T, Guo S, et al. Safety and efficacy of microwave versus radiofrequency ablation for large hepatic hemangioma: a multicenter retrospective study with propensity score matching. Eur Radiol [Internet]. 2022 May 1 [cited 2023 Jul 31];32(5):3309–18. Available from: https://doi.org/10.1007/s00330-021-08425-4
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- Philipp J, Schmidberger J, Schlingeloff P, Kratzer W. Differentiation of hepatic alveolar echinococcosis with a hemangioma-like pattern compared to typical liver hemangioma using contrast-enhanced ultrasound: a pilot study. Infection [Internet]. 2023 Feb 1 [cited 2023 Jul 31];51(1):159–68. Available from: https://doi.org/10.1007/s15010-022-01866-z
- Shin N, Choi JA, Choi JM, Cho ES, Kim JH, Chung JJ, et al. Sclerotic changes of cavernous hemangioma in the cirrhotic liver: long-term follow-up using dynamic contrast-enhanced computed tomography. Radiol med [Internet]. 2020 Dec 1 [cited 2023 Jul 31];125(12):1225–32. Available from: https://doi.org/10.1007/s11547-020-01221-y
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