Giant Hepatic Hemangioma With Secondary Portal Hypertension: 734

Hepatic hemangiomas, the most common benign hepatic tumors, are typically small (< 1 cm) and asymptomatic. Giant hemangiomas measure >4 cm and can have varying clinical manifestations due to associated compression, bleeding, necrosis, thrombosis or infarction. We present a rare case of a giant hepatic hemangioma with secondary portal hypertension. A 71 year old female with past medical history of hepatic hemangioma (diagnosed 14 years prior, s/p central hepatectomy 7 years prior resulting in size decrease from 18.7 x 13.6 cm to 10.6 x 9.9 cm), transient ischemic attack (on clopidogrel), and hypertension presented with 6 months of progressively worsening epigastric pain, early satiety, nausea, and small-volume hematemesis, in addition to an unintentional 30-lb weight loss over the past year. On the present admission, vital signs were within normal limits. Physical exam was significant for right upper quadrant and epigastric tenderness to palpation, as well as hepatomegaly. Pertinent labs include alk phos 212 U/L and platelets 81,000/UL; liver function tests, autoimmune and viral hepatitis studies were normal. CT abdomen/pelvis with and without IV contrast revealed a 16.5 x 13.0 cm complex lesion in the left liver lobe occupying over 50% of the liver volume with compression of the IVC, an enlarged but patent portal vein, and splenomegaly with esophageal and splenic varices. Abdominal duplex ultrasound showed mildly elevated resistive index within the hepatic artery and patent hepatic vasculature with normal flow through the portal vein. EGD revealed two columns of small esophageal varices in the distal esophagus with no high-risk features and no evidence of recent bleeding, a small hiatal hernia, and mild gastritis. Surgery was deemed high-risk due to size of the mass and its proximity to the IVC. The patient was started on daily pantoprazole, after which her epigastric symptoms steadily improved. She followed up as planned with interventional radiology (IR) as an outpatient and successfully underwent hemangioma embolization. This is a unique case of a partially resected, recurrent giant hepatic hemangioma with mass effect on the portal vein, causing portal hypertension and subsequent development of esophageal and splenic varices with splenomegaly and platelet sequestration. The patient's early satiety, weight loss, pain, and nausea were likely due to gastric compression by the mass. Hematemesis was attributed to gastritis in the setting of clopidogrel use. While it can be argued that most giant hepatic hemangiomas can be non-operatively managed, operative strategies should be considered for significant symptoms and complications. This patient was a poor surgical candidate, thus IR embolization of the hemangioma was deemed the optimal strategy for symptom relief.Figure 1