Torsion of a giant pedunculated liver hemangioma: Case report

Abstract

Introduction: Hepatic hemangioma (HH) is the most common benign neoplasm affecting the liver. Most cases are asymptomatic and incidentally found at imaging studies. Giant hepatic hemangiomas are uncommon, but pedunculated giant hemangiomas are even rarer, making their clinical and imaging diagnosis a challenge for the surgeon.

Presentation of case: Herein; we report the case of a 26-year-old male patient, who presented to the emergency ward with acute abdominal pain associated with a palpable mass, mimicking a complicated appendicular plastron, additionaly were found it liver enzymes elevated. Then the patient was taken the operating room. An exophytic pedunculated liver tumor that projected towards the right iliac fossa was identified. It had undergone torsion on its pedicle. Transfixing hemostatic sutures were placed, proceeding with its exeresis. The patient tolerated the procedure and was discharged without complications on the third postoperative day. Pathological anatomy confirmed the diagnosis.

Discussion: Giant pedunculated HH is an infrequent entity that generates mass effect on intra-abdominal organs causing pain depending on its location. In our case, HH size was 13 cm with elevated liver enzymes, only previously reported in one case of a 20-cm hemangioma. Surgery is indicated for cases of giant and symptomatic lesions.

Conclusion: Torsioned pedinculated giant liver hemangioma may be part of the differential diagnosis of a patient with acute appendicitis with elevated liver enzymes. The elevation of liver enzymes may be related to the size of the HH.

Keywords: Case report; Cavernous hemangioma; Hepatic hemangioma; Liver tumors; Pedunculated giant hemangioma.

Fig. 1

Contrast-enhanced abdominal CT scan. a Coronal section: giant intraperitoneal hemangioma (yellow arrow) with a vascularized pedicle originating from segment IV (red arrow). b Axial section: shows the pedicle dependent on hepatic IV-B segment, with scarce contrast enhancement and tortuosity like the whirlpool sign (blue arrow).

Fig. 2

Cavernous Hepatic Hemangioma: Exophytic lesion with a vascularized appearance dependent on the liver with a wide pedicle originating from liver segment IV.

Fig. 3

Giant Hepatic Hemangioma: A twisted pedicle originating from hepatic segment IVB is seen.

Fig. 4

Cavernous Hepatic Hemangioma: Proliferation of blood vessels of variable caliber with marked sinusoidal dilation and thinned walls covered by endothelium without atypia, occasionally filled with intraluminal thrombi over a hemorrhagic fibrous stroma.