Hepatic hemangioma - background hepatic steatosis

Case contributed by Dr Bruno Di Muzio


RUQ pain.

Patient Data

Age: 65 years
Gender: Male



The liver is mildly enlarged measuring 15.9 cm in the mid clavicular line and demonstrates diffusely increased echogenicity in keeping with fatty infiltration.  There is a small area of focal fatty sparing seen adjacent to the gallbladder.

Within segment II of the liver, there is a heterogeneous lesion, which is predominantly hypoechoic, with ill-defined margins, measuring approximately 5.0 x 4.5 x 4.3 cm.  No internal vascularity demonstrated within this.
No other focal liver lesion identified.
The main portal vein is of normal caliber measuring 1.3 cm and demonstrates normal direction of flow.

The gallbladder is nontender and thin-walled with no calculi or sludge identified. The common bile duct was poorly seen due to overlying bowel gas. The visualized common bile duct did not appear dilated measuring 3 mm. No intra-hepatic duct dilatation.

The pancreas was not well seen.
The visualized aorta is of normal caliber measuring up to 2.0 cm.

Normal spleen size of 12.1 cm.
No free fluid.

Both kidneys are normal in size, the right kidney measuring 10.5 cm and the left kidney measuring 12.9 cm.  Both kidneys demonstrate normal corticomedullary differentiation normal renal cortical thickness.  No hydronephrosis.

The lesion within the left lobe of the liver is mildly hypodense on non-contrast imaging.  This demonstrates peripheral nodular enhancement on the arterial phase imaging, with progressive and more central enhancement on portal venous and delayed phase imaging.  The lesion has approximate dimensions of 50 x 55 x 43 mm (AP x ML x SI).

The liver appears diffusely mildly hypoattenuating in keeping with mild fatty infiltration.  There is a tiny hypodense focus within segment VIII of the liver measuring 4 mm which is too small to further characterize.
Arterially enhancing small lesions in segment VII measuring 8 mm, segment VIII measuring 8 mm, and segment VI measuring 9 mm are likely flash filling hemangiomas.

The gallbladder, spleen, adrenal glands and kidneys are unremarkable in appearance.  There is a small volume of stranding seen around the pancreas, particularly the pancreatic tail.  The pancreas itself demonstrates homogeneous enhancement.
No dilated loops of the small or large bowel.  Diverticular disease of the sigmoid colon.  No free fluid or free gas.

Ill-defined nodular ground-glass density within both lower lobes and the visualized posterior aspect of the right middle lobe.  There is also mild bronchial wall thickening seen within both visualized lower lobes.
No suspicious bony lesion.

-55 mm lesion within the left lobe of liver, compatible with a hemangioma.
-Three further subcentimeter enhancing liver lesions are compatible with further small flash filling hemangiomas.
-Background hepatic steatosis - referral to fatty liver clinic recommended.
-Trace of stranding around the pancreas particularly the pancreatic tail, raises suspicion for a component to mild acute pancreatitis in the correct clinical setting.

Case Discussion

Incidental focal liver lesion in an adult patient with diffuse steatosis. As most solid liver lesions on ultrasound, appearances are non-specific and, at this age, primary or secondary liver malignancy needs consideration. Workup with 4phase liver CT was recommended and demonstrated typical features of liver hemangioma, including a few other smaller benign lesions not seen on ultrasound. 

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