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SAS Journal of Surgery Giant Hepatic Hemangioma Causing Multiple SAS Journal of Surgery ISSN 2454-5104 SAS J. Surg., Volume-2; Issue-5 (Sep-Oct, 2016); p-189-194 Available online at http://sassociety.com/sasjs/ Case Report Giant Hepatic Hemangioma Causing Multiple Pressure Effects in a Teenage Girl: A Case Report Prasenjit Chattopadhyay1, Sujata Chattopadhyay2 1Department of General Surgery, Medical College and Hospital, 88,College Street, Kolkata, West Bengal, PIN-700073, India 2Department of Anatomy, R.G. Kar Medical College and Hospital, 1, Kshudiram Bose Sarani, Kolkata, West Bengal, PIN-700004, India *Corresponding author Prasenjit Chattopadhyay Email: [email protected] Abstract: Hemangioma, as is known as the most common benign primary tumour of liver, is usually asymptomatic. They are usually less than 3 cm and can be solitary or multiple in number. Asymptomatic hemangiomas of liver need no surgicel intervention and masterly inactivity is suggested. But the rare symptomatic ones are vulnernable for various dreadful sequelae and hence operative intervention is indicated. We here report a case of 16 yr old girl presenting with symptoms of intermittent small bowel obstruction and Inferior venecava compression due to the presence of a Giant Hepatic Hemangioma. Keywords: Giant Hepatic Hemangioma, Liver, Hemangioma, Wedge resection of liver, Non anatomic resection of liver, Subacute Intestinal obstruction, Inferior Venecava Syndrome INTRODUCTION simultaneously. Presence of multiple compressive Being the most common primary benign lesion symptoms in the same patient with GHH is something of liver, hepatic hemangiomas are usually less than 3cm which is very less discussed in literature. Our study in size, a significant proportion of which are aims to present such a rare case with its rarest asymptomatic [1-4]. Their prevalence are complications to our readers. approximately 1-20% in general population and 7 % in autopsies [5-8]. Their incidence is higher in women, as CASE HISTORY a result of influence of sex hormones on their growth A 16 year old girl presented to a District [9]. Hospital with the complain of pain and abdominal distension with nausea, vomiting and menstrual Regarding the terminology Giant Hepatic irregularity for last 6 months. The patient was Hemangiomas are referred to hemangiomas of liver of apparently normal 6 months back when she felt size more than 4cm and they represent 10 percent of all heaviness in the lower abdomen which gradually hepatic hemangiomas [10-15]. In 40 % of the patients increased over the last 3 months. The patient reported a with giant hepatic hemangiomas, symptoms have been loss of weight of about 10kg during the last 3 months. reported of which abdominal pain is the most common Abdominal examination clinically revealed a mass in followed by pressure symptoms like early satiety, the central abdomen and encroaching the hypogastrium. nausea, vomiting, cholestasis, or even cough [16-19]. CT imaging demonstrated a very large solid cystic Rare presentations are spontaneous rupture presenting abdomino-pelvic lesion with relatively small solid as chylous ascites and hemoperitoneum. Others are cystic mass in adnexa suggestive of bilateral ovarian Kasabach Meritt syndrome in which hepatic neoplasm and a well defined hypodense wedge shaped hemangioma is associated with thrombocytopenia and lesion in the right lobe of liver. Blood counts were intravascular coagulation [20-22]. Even rarer normal. Midline laparotomy was carried out left complications are associated with GHH like intestinal salpingo-oophorectomy was done for left ovarian obstruction, Budd-Chiari syndrome and inferior haemorrhagic cyst which was measuring 6 cm * 6 cm. venecaval syndrome. A huge vascular SOL was found to be originating from the right lobe of liver which showed bloody content on Here we report a case of giant hepatic aspiration. Due to the vascular nature of the tumor and hemangioma in a 16 year old girl with both subacute lack of experienced surgeon, the operation was intestinal obstruction and IVC syndrome occurring concluded a patient was referred to our centre after her 189 Prasenjit Chattopadhyay et al., SAS J. Surg., 2016; 2(5):189-194 discharge with the diagnosis of Giant Hepatic lacs/cumm, INR-1.2, Bilirubin Total/direct- 0.9/0.2 Hemangioma. The patient on admission had features of mg/dl, AST-25 iU/l, ALT- 27 iU/l, Alk Ph- 591 iU/l, subacute intestinal obstruction such as recurrent albumin 3.3 gm/dl, AFP- 0.89 iU/ml. Other tumor vomiting, abdominal pain with distension and markers along with hepatitis profile was normal. Triple occasional constipation. She too had features of Inferior phase MDCT revealed a large well defined venecaval syndrome like swelling of lower limbs with heterogeneously enhancing solid mass of 19.2cm * palpitation on lying on back or right side. These 11.2cm * 20.4cm noted in the right lobe of liver symptoms were relieved on sitting or standing and on extending from right side of the abdomen below upto lying on the left lateral position. At our centre blood the right iliac fossa compressing both the small bowel tests were done which showed Hemoglobin- 11gm/dl, loops and infrahepatic IVC (Figure 1). total leukocyte count-11,300/cumm, platelet-2.5 Fig-1: CTscan WA showing the GHH in different planes A-Axial B,C-Coronal D-Sagittal After a period of 6 weeks we proceeded for the hypogastrium and right iliac fossa. After operative intervention. Preoperatively the patient adhesiolysis in the pelvic cavity due to adhesions weighed 52kg. A Chevron incision was made. A huge caused by previous surgical intervention, the huge mass mass continuous mass with the inferior surface of right was delivered out of the abdomen (Figure 2). lobe of liver (Segment 5 and 6) was found encroaching 190 Prasenjit Chattopadhyay et al., SAS J. Surg., 2016; 2(5):189-194 Fig-2--Delivering the GHH out of the abdomen There was no infiltration in any adjacent healthy liver tissue from Segment 5 and 6. The defect bowel or great vessels. Cholecystectomy performed and was primarily sutured with catgut over a surgical a wedge resection of the exophytic growth was carried (Figure 3). out by means of a harmonic scalpel taking a 2 cm Fig-3: Suture of the defect in liver after wedge resection of the GHH The procedure took nearly 1 hour with weighed 12 kg, solid in consistency with soft and cystic approximately 400ml of blood loss. The specimen degenerations at places on cut section (Figure 4). 191 Prasenjit Chattopadhyay et al., SAS J. Surg., 2016; 2(5):189-194 Fig-4: Cut section of the specimen Histopathology confirmed hemangioma of pressure effect on the hepatic veins and inferior liver. Post operatively the patient had an uneventful venecava [29]. Complications of intestinal obstruction course and her symptoms were totally relieved. On 1 can be acute or subacute. It is due to the compression of month and 6 month follow up, the patient was small bowel loops by the enlarged mass. Complete absolutely normal on the basis of physical examination, obstruction is uncommon due to the peristaltic activity biochemical and radiological investigations. and the elastic distensibility of the bowel. DISCUSSION Diagnosis can be made by radiological Hemangiomas are hamartomas caused by investigations. Ultrasonography is the initial proliferation of vascular endothelial cells over time. investigation showing homogenous hyperechogenicity. Hemangiomas though are found most commonly in the Confirmation can be done by triphasic Computed skin of head and neck, are common in all surface and tomography (CT) and Magnetic Resonance Imaging organs of the body including liver. Conventional (MRI). In case of diagnostic uncertainty , Tc 99m hepatic hemangioma are smaller in size and do not labelled RBC SPECT is of immense help. PET is used cause any symptoms. They are more common in women to differentiate between heterogenous hepatic between 30 yrs to 50 yrs. The etiology is still hemangioma and Angiosarcoma [23]. Angiography is controversial, as the relation between female sex the gold standard in the diagnosis of hemangioma hormone and HH is unclear in literature [25-28]. having invasiveness as its major disadvantage. It is of diagnostic help when the diagnosis of hepatic Most hepatic hemangiomas are incidentally hemangiomas from other malignant tumors could not be diagnosed during radiological tests done for different ruled out [5]. other complaints. The manifestations are based on 2 factors - the size and the location of the lesion. 40% of Close monitoring is recommended for small the hemangiomas which are more than 4 cm and 90% of and asymptomatic hepatic hemangioma [13, 14, 29]. the hemangiomas more than 10cm diameter are Whereas for its giant variant which are mainly symptomatic. symptomatic there are a lot of treatment options. They are enucleation, hepatic resection- non anatomic wedge Most frequent symptom of GHH is pain which resection and anatomic resection, hepatic artery are caused due to stretching of Glissons capsule, ligation, transcatheter embolisation, and recent therapy thrombotic transformation of hemangioma, necrotic with Radiofrequency ablation (RFA) [24]. Other recent degeneration and intratumoral hemorrhage. Other advances are systemic corticosteroid and Interferon features of Gastric outlet obstruction like nausea treatment [30]. Liver transplantation is the last option. ,vomiting, epigastric fullness can be present [11, 14]. Rare complications which have been mentioned in The indications of surgical treatment can be earlier case reports are Kasabach Meritt Syndrome summarised as tumor size more than 5cm, peripherally causing thrombocytopenia, microangiopathic located, persistent abdominal pain, suspicion of haemolytic anemia and consumptive coagulopathy [20- malignancy and compressive symptoms like gastric 22]. Clinical findings of Budd-Chiari syndrome and outlet obstruction, portal hypertension, obstructive Inferior Venecaval Syndrome may develop due to 192 Prasenjit Chattopadhyay et al., SAS J. Surg., 2016; 2(5):189-194 jaundice, intestinal obstruction, inferior venecaval 6. Choi BY, Nguyen MH; The diagnosis and syndrome, etc., [11, 14]. management of benign hepatic tumors. J Clin Gastroenterol., 2005; 39:401-12.
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