Presentation
Acute abdominal pain.
Patient Data
Massively enlarged liver which is largely replaced by a giant cavernous hepatic hemangioma, which has peripheral, nodular areas of discontinuous enhancement throughout.
Smaller hemangiomata throughout anteriorly displaced liver parenchyma. Note long hepatic venous drainage through the hemangioma.
Cholelithasis. Pericholecystic fluid is favored to be reactive.
Acute interstitial pancreatitis with mild ductal dilation. Tiny density layering in the distal CBD could be a small stone.
Older comparison study shows progressive (but slow) filling in of the hemangioma on arterial and portal venous phases.
Case Discussion
Strikingly large giant hepatic cavernous hemangioma. This has the potential of distracting from the acute issue, which is acute pancreatitis. The pancreatic ductal dilation, gallstones, and possible small stone in the distal CBD raises the possibility of gallstone pancreatitis, which could be future evaluated with MRCP or ERCP.
Despite the size of the hemangioma, it is a chronic finding. It is helpful to realize how large these can get, and at this size, it would be appropriate to recommend subspecialty evaluation for follow-up recommendations to ensure no rapid growth or consumption coagulopathy occurs.
Teaching points1:
- "giant" > 5 cm
- usually asymptomatic, may have mass effect
- associations: Klippel-Trenaunay-Weber, Osler-Rendu-Weber, and von Hippel–Lindau
- complications: hemorrhage, consumption coagulopathy (Kasabach-Merritt)
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