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    Prof. of Hepatology & Gastroenterology, Cairo University.

    Consultant of Hepatology,Gastroenterology and Endoscopy

    Management Positions: •

    Chief of Hepatology unit El Manial University Hospital (1994-1998).

    • Chief of Gastroentero ICU in Cairo university hospital (1997-2000)

    • President of the board of AlfaScope GI Specialized center (2004-2014).

    • Head of Endoscopy Unit in Cairo University Hospitals (2005-2010).       


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    استاذ الكبد و الجهاز الهضمى بكلية الطب جامعة القاهرة

    استشارى الكبد و الجهاز الهضمى و المناظير

    دكتوراه امراض الكبد و الجهاز الهضمى من كلية الطب جامعة القاهرة

    الرئيس السابق لقسم الامراض الباطنية بكلية الطب جامعة ٦ اكتوبر

    الرئيس السابق لوحدة مناظير الجهاز الهضمى و مركز الكبد و الرعاية المركزة بقصر العينى


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Hepatic Hemangiomas

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Hepatic hemangiomas


Hepatic hemangiomas (cavernous hemangiomas) are the most common benign hepatic tumors, representing about 70% of HFLs diagnosed during MRI. Their prevalence from autopsy reports reaches up to 20%. They are more common in women (3:1).


Hepatic hemangiomas are considered to be vascular malformations or hamartomas of congenital origin that enlarge by ectasia rather than by hyperplasia or hypertrophy.

Hormonal influence over tumor growth is suggested by enlargement during pregnancy and estrogen & progesterone therapy and regression after withdrawal of therapy.


Hemangiomas are often solitary, but multiple lesions may be present in up to 40% of patients. They can be found in both lobes of the liver but are more common in the right lobe. They may be associated with hemangiomas in other organs, biliary hamartomas, and focal nodular hyperplasia.

They range in size from a few millimeters to over 20 cm. The majority are <5 cm. The larger lesions may be pedunculated.

Microscopically, the tumor is composed of cavernous vascular spaces of varying sizes lined by a single layer of flat endothelium and filled with blood.

Clinical picture:

 Most patients with hepatic hemangiomas are asymptomatic and are typically discovered incidentally at laparotomy, autopsy, or during imaging performed for unrelated conditions.

Symptoms are more likely with large lesions (>5 cm) in young women.

The most common symptoms are

 right upper quadrant pain, discomfort or fullness. Less common symptoms include nausea, anorexia, and early satiety. Acute abdominal pain can result from thrombosis or bleeding within the tumor. It can last up to 3 weeks and be associated with fever & abnormal liver function tests.

Giant hemangiomas in children have been associated with high output cardiac failure and hypothyroidism. Hypothyroidism is due to the presence of high levels of 3 iodothyronine deiodinase in the hemangioma tissue, which catalyzes the conversion of T4 & T3 to biologically inactive hormones.

Cutaneous hemangiomas in children may be a marker for hepatic hemangiomas.  

Physical findings may occasionally reveal a palpable liver or mass. A bruit is rarely heard over the hemangioma.

Liver function tests are usually normal, unless there has been a complication such as thrombosis, bleeding, or compression of the biliary tree. Alpha fetoprotein is normal.

The majority of hemangiomas remain stable over time. Significant growth has been demonstrated in occasional patients with resultant symptoms and need for surgical resection. Spontaneous or traumatic rupture is rare. Iatrogenic rupture or intratumoral bleeding has been described following liver biopsy or fine needle aspiration.


1. Ultrasonography:

The typical appearance is well-demarcated homogeneous hyperechoic focal lesion.

The hemangioma may be hypoechoic in patients with fatty infiltration of the liver due to the bright signal from the surrounding parenchyma.

Lesions >5 cm had mixed echogenicity, probably because of intratumoral thrombosis and fibrosis.

The diagnosis of hemangiomas can be strongly suggested by ultrasound in 80% of patients with lesions <6 cm.

Color Doppler does not improve the accuracy of ultrasound.

The appearances of a hemangioma on ultrasound overlap with those of HCC & hepatic metastases. Follow-up recommendations for patients with ultrasound appearance of a hepatic hemangioma are conflicting. It is suggested that patients with a history of liver disease or known or suspected extrahepatic malignancy should undergo a confirmatory examination such as a contrast enhanced CT or MRI. While in patients with no evidence of liver disease or extrahepatic malignancy and "typical" appearances of hemangioma on ultrasound, an acceptable alternative is to repeat the ultrasound at 3-6 months to document stability.

Contrast enhanced ultrasonography:

Hepatic hemangiomas have a peripheral globular contrast pooling in the early phase that become larger and more numerous in later phases. One study reported 79% sensitivity 100% specificity for the diagnosis of hemangioma by this modality.

3. Computarized Tomography:

A non-contrast enhanced CT of a hemangioma usually demonstrates a well-demarcated hypodense mass

The lesions may appear as hyperdense relative to the surrounding parenchyma in patients with fatty infiltration of the liver.

The administration of contrast results in a peripheral nodular enhancement in the early phase, followed by a centripetal pattern or "filling in" during the late phase.

3. Magnetic resonance imaging:

MRI diagnoses hemangiomas with 90% sensitivity and 91-99% specificity.

MRI with gadolinium shows early peripheral nodular or globular enhancement on arterial phase imaging with progressive centripetal enhancement or "filling-in" on delayed scans similar to that seen on CT scanning.

4. Liver biopsy:

The role of fine needle aspiration (FNA) of a suspected hemangioma is still debatable. The procedure has been associated with fatal hemorrhage, especially in large superficial lesions in subcapsular locations. In addition, it has a low diagnostic yield.


 Asymptomatic patients, particularly those with lesions <5 cm, can be reassured and observed. Follow-up of patients with lesions >5 cm, particularly those in a sub capsular location is justified as rapid growth of such hemangioma has been reported.

Surgical intervention is indicated with complications, as rupture and intraperitoneal bleeding, with incapacitating symptoms, or with failure to exclude a malignancy.

Surgical methods for the treatment of hemangiomas include; liver resection, enucleation, hepatic artery ligation, and liver transplantation.

Arterial embolization has been used to control acute bleeding and symptoms, but it may be complicated by abscess formation, and there is no evidence of long-term efficacy.

Last Updated on Thursday, 18 May 2017 11:14


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