Spontaneous rupture of a liver hemangioma. A case report

Rotura espontánea de hemangioma hepático no conocido

María Pilar Guillén-Paredes, Josefa Martínez-Fernández, Álvaro Morales-González and José Luis Pardo-García

General and Digestive Surgery Department. Hospital Comarcal del Noroeste. Caravaca de la Cruz. Murcia, Spain

A 78-year-old man, with previous history of high blood pressure, came to the Emergency Department with complaints of intensive abdominal pain in the last 2 hours with no other related symptoms. Physical examination determined: blood pressure, 70/45 mmHg; heart rate, 110 bpm; superior abdominal pain with tenderness. Initial management was undertaken, and blood pressure went over to 120/70 mmHg. Lab report: hemoglobin, 12 g/dL; 84,000 platelets/µL; prothrombin activity, 84%; the rest of parameters were normal. A computer tomography (CT) scan was performed (Fig. 1). An emergency surgery was required, and two liters of hemoperitoneum were found by a right hepatic lobe's ruptured tumor with active bleeding. A right hepatectomy was undertaken. Ten units of packed red blood cells were administered to the patient. A liver failure developed progressively, the patient being exitus in the fifth postoperative day. The study of the resected tumor confirmed the diagnosis of a 12 cm liver hemangioma.

Discussion

Hemangioma is the most common benign liver tumor. Spontaneous rupture of a liver hemangioma is not a usual complication but can be a dramatic event because it is associated to a 75% of mortality (1).

Only 30 similar cases have been described in the literature (2-4), being more frequent in giant hemangiomas. It is caused by an internal bleeding and a sudden increase of pressure inside the tumor. This produces an "open-book" rupture of the liver parenchyma, causing a massive hemoperitoneum (5).

The packing management in case of rupture tumors has a low rate of success, unlike packing for liver trauma, which is very effective and safe. Although liver packing can be the first measure to be taken to control bleeding, it has a high failure rate, causing re-bleeding, and high perioperative mortality. Therefore, the emergency treatment is controversial. Transarterial embolization (TAE) is not well-indicated in case of unstable patients, being the surgical approach indicated in these cases. TAE also has a very variable success rate, from 53% to 100% (4). Moreover, the most common complication is the post-embolization syndrome (85%), followed by liver failure (34-50%) and hemostasis failure (20%). In conclusion, TAE is not a harmless technique and must be selectively indicated in patients with a good liver function, acceptable coagulopathy and a permeable portal vein (3,4). So, although TAE is a less invasive technique than open surgery, hepatic resection allows a better hemostasis of the bleeding area and a longer survival.

1. Jain V, Ramachandran V, Garg R, et al. Spontaneous rupture of giant hepatic hemangioma-sequential management with transcatheter arterial embolization and resection. Saudi J Gastroent 2010;16:116-9. DOI: 10.4103/1319-3767.61240.         [ Links ]

2. Doklestic K, Stefanovic B, Karamarkovic A, et al. Spontaneous rupture of giant liver hemangioma: Case report. Srp Arh Celok Lek 2013;141:95-99. DOI: 10.2298/SARH1302095D.         [ Links ]

3. Yamamoto T, Kawarada Y, Yano T, et al. Spontaneous rupture of hemangioma of the liver: Treatment with transcatheter hepatic arterial embolization. Am J Gastroenterol 1991;86:1645-9. DOI: 0002-9270/91/8611-1645-03.00/0.         [ Links ]

4. Corigliano N, Mercantini P, Amodio PM, et al. Hemoperitoneum from a spontaneous rupture of a giant hemangioma of the liver: Report of a case. Surg Today 2003:33;459-63.         [ Links ]

5. Coca A, Munné P, Anguita A, et al. Abdomen agudo por hemoperitoneo como primera manifestación de un tumor hepático. A propósito de cuatro casos. Med Clin 1979;72:97-102.         [ Links ]