Recently, a male patient resorted to the emergency department of CHUC-Hospital Geral (Covões) in Coimbra, Portugal, complaining of abdominal pain in the right upper quadrant, without other signs or symptoms. He was hemodynamically normal. Ultrasound found a hepatic image of about 9cm, suspected of being an abscess. However, patient had neither fever nor leukocytosis. A CT scan concluded for a hepatic hemangioma with active bleeding inside it, without rupture. Our option was ask for a transcatheter hepatic arterial embolization. Full success. But… What should we have done if a rupture was present?
Hepatic hemangioma is the most frequent benign tumor found in the liver. Usually its diagnosis is incidental, and in the majority of cases it is asymptomatic and treatment is not necessary. If a hemangioma is larger than 4 cm is a “giant hemangioma”, and can produce symptoms. Although vague abdominal symptoms are the most frequent, mass effect can cause abdominal fullness, early satiety, nausea and vomiting.
Hepatic hemangioma is giant if larger than 4 cm. Treat if there are symptoms or complications.
Treatment is only indicated in symptomatic cases, or if there is evidence of haemorrhage, rupture or in diagnosis uncertainty situations. Spontaneous rupture of a hepatic hemangioma is a rare but life threatening condition. From all cases reported in literature (32), a spontaneous rupture of a hepatic hemangioma ended in laparotomy and resection. Even the four cases reporting arterial embolization as first option, there was a re-bleed followed by resection. So… Is this the lesson to learn? Does spontaneous rupture means resection? Not so fast!
Surgeons Tony Green and John D’Emilia from Stratford, New Jersey, published in 2007 a case report of a female patient with a spontaneous rupture of a giant hepatic hemangioma, with substantial hemoperitoneum, treated with transcatheter hepatic arterial embolization. There was no re-bleeding, and no resection or other treatment was needed. According to the authors this was the first successful case of a spontaneous rupture of a hepatic hemangioma treated only with arterial embolization.
Transcatheter hepatic arterial embolization was the only treatment needed to deal with a spontaneously ruptured giant hepatic hemangioma.
The authors state that embolization has become a frequent treatment in blunt and penetrating hepatic trauma. Although it comes with morbidity (hepatic necrosis, abdominal abscess, biloma, bile leak), it improved patients’ outcomes.
Will this shift our approach towards conservative measures? Will us surgeons move faraway from surgical treatment in the presence of a hepatic hemangioma? In my opinion this is only one case, but an important one. We must not forget that a spontaneous rupture is extremely rare, and so there cannot be a huge study to take statistically valid conclusions. Clinical reports are the only tools that can help us decide, emphasizing the importance of publishing and sharing experiences. From all cases reported, 84% were giant hemangiomas, which gives us the idea that size matters when dealing with hepatic hemangiomas. Additionally, this means that if a resection is the only way to treat a spontaneous rupture, you will probably face the need to perform a major hepatic resection (of a giant hemangioma) in an unstable patient. Scaring!
Embolization can give you time if definitive treatment is not reached.
This report from Tony Green leave us the concept that transcatheter hepatic arterial embolization can eventually solve the problem with out the need of a resection. The authors also discuss that arterial embolization can give the doctor time to stabilize the patient before an eventual hepatic resection if a re-bleeding occurs. So, in my opinion, transcatheter hepatic arterial embolization should eventually be the first option to treat a hepatic hemangioma (giant or not) with a spontaneous rupture. If it doesn’t solve the problem, it will give you time to prepare the patient (and yourself) for resection.
Remember to share your cases. Only in this way we can evolve in the right direction.
Link to Article:
Dr. Carlos Eduardo Costa Almeida
General Surgeon