Teaching Case

A 68-year-old male patient first presented to the emergency department with complaints of abdominal pain, which was acute in onset and located more in the right hypochondrial region. On clinical examination patients vitals were suggestive of hypotension. Blood work-up was suggestive of low heamoglobin concentration.

An emergency portable ultrasound showed a large liver lesion of mixed echo-texture and free fluid in the pelvis. After establishing haemodynamic stability, a contrast-enhanced CT abdomen was planned. CT abdomen showed liver to have multiple incidentally detected lesions which showed nodular peripheral enhancement on arterial phase with progressive centripetal enhancement on succesive phase and isoattenuation on delayed phase which was suggestive of haemangiomas. A large segment VI haemangioma showed a large haematoma with associated haemoperitoneum. Differential diagnosis included metastasis and cysts, which was ruled out on basis of the enhancement.
The patient was referred to the intervention radiology team to provide endovascular treatment for the dropping haemoglobin. Conventional selective angiogram of the hepatic arteries showed areas of contrast blush, for which embolisation was performed using PVA particles (300 micron) and gelfoam slurry. Control angiogram showed absence of previously noted areas. On follow-up patient showed both haemodynamic and clinical improvement.

Haemangiomas are the most common benign lesions, which are a type of congenital vascular malformations. They are usually less than 5cm in size and most of the times remain stable requiring no treatment. However, sometimes complications can arise which includes abdominal fullness, pain, inflammatory syndrome and coagulation disturbances. Pain abdomen is the most common symptom which is highly non-specific. Giant haemangiomas are referred to when lesions are more than 4 cm. These lesions are most common in females and elderly patients. IL-7 and vascular endothelial growth factor (VGEF) have been postulated to be the cause for formation of the lesion [1-3]. 5% of patients are at risk of spontaneous rupture [4]. Haemangioma has characteristic imaging features on USG, CT and MRI. The first preferred option of treatment is surgery. Less invasive therapeutic techniques such as trans-arterial embolisation, radio-frequency ablation and radiation surgery have been employed for the treatment of the condition. Initially embolisation was employed to reduce the size of the lesions prior to surgery, however, this has now been replaced by only a single step procedure of embolisation [5]. Ruptured haemangiomas are associated with mortality rate of up to 70% [6]. Embolisation is indicated in a) lesions >4 cm, b) increase in the size of the lesion, c) Kasabach-Merritt syndrome, d) ruptured lesion e) surgical risk, f) lesion causing mass effect and g) surgical risk. Variois embolic materials have been used including bleomycin with lipiodol, PVA particles, gelfoam and foam. Complications associated with the procedure include nausea, vomiting, abdominal pain and dullness, fever and biliary abnormalities.
Embolisation is a highly effective and safe procedure and a alternative for surgery.

Written informed patient consent for publication has been obtained.