Overview.
Benign tumors of the liver caused by abnormal vascular development during embryonic development.
Generally asymptomatic, may have abdominal mass and discomfort, mostly found during physical examination.
Treatment mainly includes resection of hemangioma
It occurs at any age, and is more common in 40-60 years old, with a higher incidence in females than males.
What is hepatic hemangioma?
Definition
Hepatic hemangioma is a common benign tumor of the liver caused by abnormal development of blood vessels during embryonic development.
It is common as a solitary tumor, with cavernous hemangioma being the most common.
Diagnosis and differential diagnosis are mainly made by imaging.
When there is no compression symptom, no treatment is needed and the prognosis is good.
If the volume is too large, it may compress the neighboring organs, and in serious cases, it may rupture and become life-threatening.
Classification
According to the amount of fibrous tissue contained in the tumor
Cavernous hemangioma, the most common.
Sclerosing hemangioma.
Vascular endothelial cell tumor.
Capillary hemangioma.
Classification according to tumor size
Small hemangioma: hemangioma diameter <5 cm.
Large hemangioma: hemangioma diameter 5-10 cm.
Giant hemangioma: hemangioma diameter ≥10 cm.
Morbidity
Statistical analysis based on 670,000 health checkups showed that the incidence rate of hepatic hemangioma was about 1.5 %, the ratio of male to female was about 1.3:1, and the high incidence age group was from 40 to 60 years old, accounting for about 58%.
Questions you may be concerned about
Does hepatic hemangioma need treatment?
Most of the liver hemangiomas do not need treatment if there are no symptoms, and it is feasible to conduct medical observation and regular review of ultrasound, etc. Treatment should be considered when the patient’s study, work and life are seriously affected by the psychological pressure caused by the existence of the disease.
When there are obvious clinical symptoms, rapid growth, tumor >4cm or liver cancer cannot be excluded, treatment should be carried out in time.
What causes hepatic hemangioma?
Hepatic hemangioma is usually thought to be caused by abnormal vascular development during embryonic development.
Acquired is mainly related to hormone levels, and elevated levels of estrogen and progesterone in the body can lead to tumor growth. This may be one of the reasons for the higher incidence of hepatic hemangioma in women.
Some scholars also think that it is the deformation of capillaries in the liver after infection, which causes capillaries to dilate into vacuoles, and its surrounding blood vessels are congested and dilated, with regional blood circulation stagnation, resulting in the formation of spongy dilatation of blood vessels.
Will hepatic hemangioma become liver cancer?
Hepatic hemangioma is a benign lesion of liver, without obvious malignant manifestation and tendency. The tumor is mainly composed of a large number of vascular tissues, separated from normal liver parenchyma by a fibrous sheath, and is usually supplied by hepatic artery, with arteriovenous fistula in some patients.
The vast majority of hepatic hemangiomas can coexist with the tumor for life because of the lack of malignant tendency, but there are still some patients with malignant transformation into hepatic hemangiosarcoma due to the progression of hemangiomas, which has a higher degree of malignancy.
Causes
Causes
Congenital factors
It is usually thought to originate from the abnormal proliferation of vascular endothelial cells.
Acquired factors
Mainly related to hormone levels, elevated levels of estrogen and progesterone in the body can lead to tumor growth, which may be one of the reasons for the higher incidence of hepatic hemangioma in women.
Other factors
Some scholars also think that it is the deformation of intrahepatic capillaries after infection, resulting in the expansion of capillaries into vacuoles, and the congestion and expansion of its surrounding blood vessels, and the stagnation of regional blood circulation, resulting in the formation of spongy expansion of blood vessels.
Predisposing factors
Female puberty, pregnancy, oral contraceptives or estrogen treatment may be prone to hepatic hemangioma.
Pathogenesis
It is generally believed to be related to abnormal development of hepatic blood vessels during embryonic period, which in turn causes angiomatous proliferation and leads to hemangioma. Vasodilatation formed by recanalization of blood vessels after mechanization of intrahepatic hematoma
Localized circulatory obstruction in the liver, leading to vasodilation.
Dilatation of capillary wall after infection, resulting in a tumor-like structure.
Vasodilatation after localized tissue necrosis.
The size of hepatic hemangioma may increase significantly in female patients during pregnancy or oral contraceptive use, and estrogen may be related to hemangioma growth.
Symptoms
Main Symptoms
Hemangioma grows slowly, mostly asymptomatic, usually detected by abdominal imaging.
As the tumor increases in size, it may produce symptoms of pulling the hepatic periosteum and compressing adjacent tissues or organs, which may include persistent vague pain in the right upper abdomen, postprandial fullness and bloating, nausea and vomiting, loss of appetite, and abdominal mass, usually without pressure pain.
Other symptoms
If the tumor ruptures and bleeds, severe abdominal pain and fever may occur.
The large size of hemangioma may exert pressure on the surrounding tissues and organs.
压迫食管下段，出现吞咽困难。
压迫胆道，出现胆汁淤积、黄疸。
压迫门脉系统，出现脾大、腹水。
挤压膈肌，引起呼吸不畅。
Complications
Kasabach-Merritt syndrome.
Rarely, patients with hepatic hemangiomas may present with thrombocytopenia, microvascular hemolytic anemia, and consumptive coagulopathy.
The prognosis is often poor due to coagulation disorders, sepsis, and damage to vital organs.
Hemangioma rupture and bleeding
Rupture and bleeding of hepatic hemangioma may cause severe pain in the upper abdomen and even shock, requiring emergency treatment.
Budd-Chiari syndrome
Narrowing and occlusion of the hepatic vein and adjacent inferior vena cava caused by giant hepatic hemangioma.
Obstruction of blood return to the hepatic vein and inferior vena cava may produce a series of clinical manifestations such as hepatomegaly, pain, ascites and liver dysfunction.
Consultation
Department of Medicine
General Surgery
Physical examination suggests the possibility of hemangioma, or symptoms such as epigastric discomfort, abdominal distension, abdominal pain, loss of appetite, nausea, vomiting, etc., it is recommended to consult the doctor promptly.
Preparation
Consultation: Registration, Preparation of Documents, Frequently Asked Questions
Tips
Before going to the doctor, try to keep a record of the symptoms you have experienced and how long they have lasted.
Preparation Checklist
Symptom list
Pay particular attention to the time of onset of symptoms, special manifestations, etc.
What tests were done to detect the hepatic hemangioma?
Were there any symptoms such as abdominal pain, bloating, etc.?
When did it appear?
What tests and treatments have been done?
List of medical history
Is it a pregnancy?
Are there any birth control pills being taken?
Checklist
Test results for the last six months to bring to the doctor’s office
Abdominal ultrasound, CT, MRI
Medication List
Medication in the last 3 months, if available, bring the box or package with you to the doctor’s office
Contraceptives: megestrol acetate, norethindrone tablets
Diagnosis
Diagnostic basis
Medical history
Time of onset of relevant symptoms.
History of taking the pill.
Whether or not during pregnancy.
Clinical manifestations
Early stages are often asymptomatic and are often detected on abdominal imaging for other reasons. When the tumor develops to >4 cm in diameter, the following symptoms may occur.
Abdominal mass
Abdominal mass without pressure pain.
Located in the right upper abdomen.
Gastrointestinal symptoms
Hidden pain and discomfort in the right upper abdomen, loss of appetite, nausea, vomiting, belching.
Dyspeptic symptoms such as bloating and fullness after eating.
Compression symptoms
When the tumor is large, it may compress the surrounding tissues and organs, and the corresponding compression symptoms of liver, bile, pancreas, stomach and diaphragm may appear.
Rupture and bleeding of hepatic hemangioma
Severe pain in the upper abdomen.
Dizziness and pallor in severe cases.
Laboratory examination
Liver function tests: abnormal liver function may occur when the hepatic bile ducts are compressed.
Thrombocytopenia may occur when combined with portal hypertension and hypersplenism.
Imaging examination
Ultrasound
Simple and non-invasive, it is the preferred imaging method.
Ultrasound of hepatic hemangioma is characterized by high echogenicity and low echogenicity with reticular structure, uniform density, regular morphology and clear boundaries.
Larger hemangiomas can be lobulated in section, and the internal echoes are still mainly enhanced, which can be tubular or irregular nodular or blocky hypoechoic areas, and sometimes there can be calcified hypoechoic and posterior acoustic shadows, which are caused by thrombosis, mechanization, or calcification of the vascular lumen.
Contrast ultrasound
In cases of hepatic hemangioma with atypical imaging presentation, selective liver contrast ultrasonography may be considered.
Typically, hemangioma ultrasonography shows nodular or circumferential enhancement in the periphery in the arterial phase, which gradually expands to the center over time.
The process of expansion is slow, and the lesion remains enhanced in the portal and delayed phases, with echoes equal to or higher than those of the surrounding liver tissue.
CT examination
CT scan shows round or round-like low-density foci in the liver parenchyma with clear boundaries, and a few of them may be irregular.
Enhancement scan has the characteristic of “fast in and slow out”.
MRI examination
MRI shows low signal in T1-weighted and high signal in T2-weighted, with uniform intensity and clear edge.
The contrast with the surrounding liver is obvious, which is described as “light bulb sign”, which is the specific performance of hemangioma in MRI.
Differential diagnosis
Hepatocellular carcinoma
Similarities: Liver mass, epigastric discomfort and other gastrointestinal symptoms.
Differences: Patients with hepatocellular carcinoma have a history of hepatitis and cirrhosis, severe weight loss, jaundice, anorexia, etc. Alpha-fetoprotein (AFP) is usually positive. Enhanced CT or enhanced magnetic resonance imaging (MRI) is also helpful for differentiation.
Liver metastases
Similarity: Liver mass.
Difference: Patients with liver metastases have a history of primary malignancy and may show edge enhancement on enhanced CT and magnetic resonance imaging (MRI).
Liver cyst
Similarities: Liver mass with symptoms such as epigastric discomfort and loss of appetite.
Differences: Liver cysts are hypointense on delayed scan and can be differentiated from hepatic hemangioma.
Treatment
Aims and principles of treatment
Most asymptomatic patients do not need treatment, and medical observation is feasible; treatment should be considered when the patient’s study, work and life are seriously affected by the psychological pressure generated by the presence of the disease.
For those with obvious clinical symptoms, rapid growth, tumors >4 cm or those who cannot exclude hepatocellular carcinoma, treatment should be carried out.
Treatment methods
Drug treatment
There is a lack of effective therapeutic drugs.
Surgical treatment
Cases requiring surgery
有症状者可考虑手术治疗。
肝血管瘤直径超过10厘米者，或血管瘤短时间内迅速增大者，可考虑手术治疗。
发生血管瘤破裂出血者需要紧急手术治疗。
Surgery
血管瘤切除术。
血管瘤缝扎术。
肝动脉结扎术。
Other treatments
Hepatic artery embolization (TAE)
The treatment of hepatic hemangioma is based on the fact that hepatic hemangioma is mainly supplied by the hepatic artery, and thrombus can be formed in the tumor after embolizing the artery.
After embolization of the artery, thrombus can be formed in the tumor, and the tumor will form fibroma-like structure by thrombus mechanization and fibrosis, so as to achieve the purpose of shrinking and hardening the hemangioma.
Microwave curing and radiofrequency treatment for hepatic hemangioma
Hepatic hemangioma microwave curing surgery and radiofrequency treatment, microwave can be converted into heat energy and make the surrounding tissues coagulate.
It can make the tumor shrink and harden locally and achieve the purpose of curing the tumor.
Prognosis
Cure situation
Since hepatic hemangiomas are benign lesions, most patients can be treated with a conservative treatment strategy of waiting for observation.
Symptomatic or larger hepatic hemangiomas can be treated surgically with good outcome and long-term survival.
The outcome after treatment of hepatic hemangioma is related to the severity of the disease and the method of treatment.
Harmfulness
Hidden pain in liver area, abdominal distension, nausea, vomiting and other symptoms caused by hepatic hemangioma can affect patients’ work and life.
Hepatic hemangioma has the possibility of spontaneous rupture or traumatic rupture with the enlargement of the tumor, once ruptured, hemorrhagic shock can occur, and the morbidity and mortality rate reaches 70%.
Hepatic hemangioma is rarely malignant, but once it turns into hepatic hemangiosarcoma, its malignant degree is higher.
Daily
Daily Management
Dietary management
Eat high quality protein food such as meat, egg and milk appropriately.
Increase the intake of fresh vegetables and fruits, and avoid excessively oily food.
Work and rest management
Maintain a relaxed and happy mood and establish a regular routine.
Avoid overwork and exposure to cold.
Maintain water intake.
Quit smoking and avoid alcohol and other stimulants.
Disease monitoring
Regular ultrasound examination is recommended to observe any changes of hepatic hemangioma.
Prevention
There is no definite preventive measure. The pathogenesis of hepatic hemangioma has not been clarified, and it is mostly believed to be related to congenital developmental abnormalities.