What is liver hemangioma?

Hemangioma is the second most common oncological pathology of the liver. This is a benign tumor from the vessels, located in the parenchyma. Hemangioma of the liver predominantly affects the right lobe. Symptoms are very scarce. Most often, pathology is detected by chance during examination for another disease. But can give heavy bleeding dangerous to life.

Hemangioma of the liver is found in 5-10% of newborns. By the age of four, the tumor disappears without treatment. Among the entire population, it is detected in 7% of the surveyed.5 times more often affects women, so one of the reasons for the appearance is the stimulating role of sex hormones of estrogens. Adult patients are treated at any age, a maximum of 30 to 50 years.

Why does hemangioma appear?

There is an opinion that a hemangioma occurs in a small child, like an anomaly of the vascular venous bundle as a result of a violation of the vascular bookmark in the embryonic state. There are supporters:

• inflammatory theory( author R. Virchow);
• communication with vasodilation after necrosis( author Ziegler);
• cavernous ectasia or cavity formation( author Schmieden).

The most popular theory is the violation of vascular embryogenesis. There is a delay of the temporal vascular channels. Specialists in oncology recognize in the hemangioma of the liver all the signs of the tumor process.

It is established that pathology is formed in utero during the first trimester of a mother's pregnancy. This is the term of the formation of large vessels and the bloodstream of the fetus. The effect of unfavorable factors on the woman's organism leads to a neoplasm. The specific causes of hepatic hemangioma are not yet clear.

To the factors causing a violation of the proper process of formation of blood vessels in the liver, include:

• harmful habits of the future mother( smoking, drinking alcohol and drugs);
• forced treatment on the background of pregnancy with potent drugs( estrogens, steroids, clomiphene, chorionic gonadotropin);
• exposure to radioactive radiation;
• concomitant lesion of the hepatic tissue with other malformations and developmental abnormalities;
• hereditary predisposition, recorded cases of family origin among close relatives.

Multiple neoplasms are more dangerous and complex in the treatment of

Types of hemangiomas and tumor characteristics

Usually, the tumor is located in one( right or left) lobe of the liver. Can occupy the whole share. More common right-sided defeat. It is possible to form a single unit with a diameter of 15 cm, rarely the size reaches 45 cm or multiple hemangiomas( the term "hemangiomatosis" is used).

The cases of surgical removal of huge tumors weighing up to 5 kg are described. Inside, the liver hemangioma consists of venous type vessels. Located in the thickness of the parenchyma, protrudes above the surface or looks like a "knot on the leg," which is connected to the liver by a large vessel. The knot is 3-18 cm in size.

On the cut, the tumor is similar to a sponge impregnated with blood. Under a microscope, vascular lacunae of various sizes are identified, separated by septa from connective tissue. The composition of the septum is identical to the vascular wall. With time, calcium salts are deposited inside the neoplasm. Haemorrhage is often seen.

In appearance, the removed tumor is dark brown or dark blue, and blue-purple is also possible. Depending on the composition of the expanded vascular cells among benign tumors, there are:

• for hemangiendothelioma;
• with a groinlike angioma;
• venous angioma;
• cavernous angioma;
• is capillary.

The differences between the forms are also:

• in the building;
• sizes;
• state of vascular caves;
• degree of filling with blood;
• presence or absence of thrombus formation;
• degree of development of connective tissue.

Hemangioma can be soft, which is caused by the presence of cavities filled with blood in the conglomerate structure. Denser tumor becomes with calcification, marked fibrosis. The most common capillary and cavernous species.

Cavernous hemangioma( cavernoma, dense hemangioma with severe fibrosis or calcification) - includes large cavities combined into one. Capillary - consists of several cavities of small size. It grows slowly, which is why it does not reach large sizes.

At a microscopy, typical lacunae with blood are identified in the cavernous form

In addition, a classification of hemangiomas according to the principle: a tumor against the background of cirrhosis of the liver, without cirrhosis, is a mixed version. It is still unclear whether cirrhosis leads to the appearance of angiomas or vice versa. According to the histological structure, the tumor is formed by cystic cavities filled with blood. They are lined with epithelium.

Hepatic cells between the cavities absent or compressed. The surrounding parenchyma is unchanged. Some experts express the conviction that hemangiomas are such a borderline neoplasm from a benign malignant liver tumor. This opinion is justified by cases of germination of hemangioma in surrounding tissues, metastasis to the lungs.

What are the complications of liver hemangioma?

Without treatment, pathology can cause severe complications. The risk is highest for a multiple process. The patients develop:

• ruptured liver with internal bleeding;
• intestinal bleeding from the biliary tract( hemobiology);
• hepatitis;
• liver cirrhosis with hepatic insufficiency;
• of jaundice;
• marked ascites;
• torsion of the knee;
• necrosis and abscess formation of the tumor;
• chronic heart failure;
• displacement of the compressed internal organs;
• thrombosis of the veins of the abdominal cavity;
• syndrome Kazabaha Merritt - a violation in the coagulation system with a drop in platelet count, intravascular thrombosis;
• malignant degeneration and metastasis.

What are the symptoms of the diagnosis and the complications?

Symptoms of liver hemangioma show clinical signs only in 30% of patients. In others, it is detected by chance during ultrasound and is asymptomatic. Usually, it does not reach significant dimensions( not more than 5 cm in diameter).Among patients with clinical manifestations, the ratio of women and men is 10: 1.

Symptoms depend on the size of the tumor, location in the organ in relation to the gate area and inferior vena cava, the degree of deformation of the hepatic tissue, complications. Complaints are caused by the progressive growth of the tumor.

Most often patients are concerned about the feeling of heaviness and aching pain in the hypochondrium to the right, nausea, vomiting, after eating a feeling of pressure in the epigastrium, "stomach overflow", vague jaundice of the skin. When palpating the abdomen, the doctor reveals an increase in the liver, in 17% of cases - a soft, slightly painful formation.

Internal bleeding is the main sign of liver hemangioma. The rupture of the vascular tumor occurs under the influence of:

• fall;
• trauma to the abdomen;
• sudden movements;
• performing physical activity.

Because of severe bleeding, the patient may die. If there are large lacunae in the hemangioma structure, then during the rupture the bleeding is massive in the abdominal cavity. The patient lives for a few minutes.

Blood transfusion is one way to save a life with a bleeding

In the presence of a large amount of fibrous tissue, the intensity of bleeding is much lower. It lasts up to three days. Pay attention to pallor, hypotension, tachycardia with palpable, enlarged liver. With large tumor sizes, hypertension develops in the portal system, heart failure.

In the first place there are complaints of increased pain in the hypochondrium to the right, edema on the legs, ascites, a tendency to hypotension with dizziness, weakness, feces become darker. Patients have signs of anemia, intoxication.

With hemangioma necrosis and abscessing, the symptomatology does not differ from liver abscess: fever with chills, pronounced pain in the hypochondrium, right and epigastric, enlargement of the liver against normal leukocytosis and biochemical hepatic tests.

The syndrome of Kazabaha Merritt is manifested by severe thrombocytopenia, diffuse point hemorrhagic eruptions on the skin. In the analysis of blood on a coagulogram, a picture similar to the syndrome of intravascular coagulation appears. The patient can be saved only by removal of the hemangioma.

How to detect pathology?

Intravital diagnosis of liver hemangioma was considered impossible even in the first half of the XX century. From the history of the problem, it is known that before 1957, a correct diagnosis was made before the operation for only eight patients. Even now, half of the patients go to the hospital not with the established diagnosis of hemangioma, but with "focal liver damage", "echinococcosis", calcification of the tumor simulates alveococcosis.

Inspection and elucidation of symptoms do not give specific symptoms. Very rare indication - listening to systolic murmur over the projection of the tumor. Blood tests establish: thrombocytopenia, fibrinogen reduction, bilirubin, liver enzymes, ESR, and hemoglobin drop are possible.

But these signs are found only at large tumor sizes. Small hemangiomas do not affect the functioning of the liver, so they do not give laboratory signs. Radiographs on the background of the introduction of air into the abdominal cavity( pneumoperitoneum) allow you to establish areas of calcified tissue.

The leading surgical clinics have accumulated experience in the diagnosis of angiography of the blood vessels of the liver. It allows to detect tumors in the size of 2.5 cm. The signs of hemangioma are:

• change in shape and displacement of the hepatic arteries near the focus;
• presence of pathological vessels with accumulation of contrast;
• increased blood flow in the study area;
• contrast relief in a large venous vessel.

The main methods in diagnostics are instrumental types. Sufficiently accessible and informative is ultrasound. Its effectiveness is enhanced by the use of Doppler and contrast.

Echocardiograms on ultrasound allow the doctor to reveal in the parenchyma of the liver a rounded formation that has clear contours, an asymmetric increase in one lobe. To confirm the connection with vascular origin, intravenously inject a contrast agent. A site with increased blood flow is determined.

Echo-negative tumor zones indicate cavities with blood

Magnetoresonant( MRI) and computer( CT) tomography with contrasting hepatic vessels help clarify the diagnosis. Methods reveal such signs of hemangioma as the exact size and location, structure, level of fluid in the vascular lacunae.

For differentiation with malignant tumors, a radioisotope study is performed, a celiacography( contrast through the catheter is introduced into the celiac trunk, all the branches, including the hepatic artery, are obtained on the angiograms), liver scintigraphy.

Liver biopsy is not used, as it can provoke a life-threatening bleeding and the development of severe complications. The method of laparoscopy is used in a limited way. Surveying the surface of the liver helps to detect the tumor only in the areas accessible to the review and, if it approaches the capsule.

Hemangioma looks like a blue-purple, tuberous growth. Differential diagnosis is performed with other neoplasms of the liver of benign and malignant nature, parasitic cysts.

Methods of treatment of hemangioma

Treatment of hemangioma of the liver is determined after a full examination in a specialized department. To decide which doctor will recommend the correct option, it is better to contact the hepatologist. These specialists are available in regional centers or private clinics.

The operative method is the only one that helps to finally cure the patient and get rid of hemangioma. Do not perform surgery to detect a tumor up to 5 cm in diameter. Such people are observed at the doctor, they are recommended to conduct ultrasound every six months for timely diagnosis of growth of the tumor.

If the patient has symptoms of liver damage without signs of complications, then medicines and minimally invasive methods are used:

• hormone therapy( also used to prepare for surgery);
• treatment by microwave and microwave therapy;
• radiofrequency ablation - causes destruction of the tumor and replacement with scar tissue;
• laser exposure - similar to the sclerosing process;
• electrocoagulation - performed with superficial tumors;
• cryotherapy.

Some of the techniques are performed in the operating room, others - allow the impact on the hemangioma under the control of equipment for computed tomography.

Surface location of a large tumor - indisputable indication for operation

Surgical treatment of hemangioma of the liver is shown:

• with single hemangiomas larger than 5 cm;
• fast-growing tumors of any size( by 50 or more percent annually);
• surface location;
• pressure on surrounding tissue;
• hemangiomas with complicated course;
• doubts in the goodness of the tumor

Contraindications are:

• revealed germination in the blood vessels of the liver;
• cirrhosis of the liver;
• multiple nature of lesion;
• pregnancy;
• presence of hematoma in the liver;
• Hormone replacement therapy.

The treating physicians choose the optimal variant of the operation in each specific case: enucleation( excision) of the tumor node - the healthy hepatic tissue, resection( removal) of the whole lobe or a separate segment is retained as much as possible - the tumor is removed together with part of the intact liver with deep lying, large size, suspicionon malignant degeneration.

To reduce blood loss in modern clinics use cryo-replication( cryo-ultrasonic or cryovibroscalpel).The equipment allows to reach a negative temperature of 160-190 degrees. For the same purpose, ultrasonic aspirators, pneumothermothermocoagulators are used.

How to treat liver hemangioma that can not be removed?

There are cases in which it is technically difficult to remove a tumor, there are doubts about the degree of risk, there are concomitant diseases in the elderly. In such cases, radiotherapy is prescribed.

If radical surgery is not possible, recommend:

• sclerotherapy - the introduction of a drug that causes fibrous tissue proliferation;
• embolization of the artery feeding the tumor - is carried out by the introduction of a catheter with a special preparation of gel consistency from polyhydroxylmethacrylate, the technique disrupts growth, leads to a decrease in the formation.

There is a method of creating a high-frequency electromagnetic field in the hemangioma zone, in which the temperature rises, which leads to the death and splitting of tumor tissues. In all cases, you should carefully approach dietary nutrition. It is necessary to prevent the load on the liver and disruption of its functioning.

The main dietary table number 5.It is not recommended to eat fatty and fried dishes, canned food, carbonated water, alcohol, dairy products of high fat content( sour cream, cottage cheese, kefir).In the menu you need to constantly enter more vegetables( salads), fruits, fresh juices.

On the photo the removed share of a liver with a large hemangioma

Is it possible to be treated with folk remedies?

Traditional medicine considers effective for hemangioma of the liver:

• alcoholic wormwood tincture;
• oat broth;
• lime tea;
• herbal infusions tansy, yarrow, celandine, shepherd's purse, plantain leaves, mother and stepmother.

Prognosis and prophylaxis

Forecast of hemangioma of the liver with small size, timely treatment - favorable. If the tumor reaches a significant value, complications should be expected, so all possible treatments should be used.

For women who want to give birth, the problem is not in the possibility of becoming pregnant, but in the way of delivery. Obstetricians-gynecologists prefer to do caesarean section to avoid rupture of the tumor.

In addition, with determination to pregnancy, it is necessary to take into account the high probability of growth of hemangioma under the influence of hormonal changes. Therefore, it is necessary to prepare, eat healthy, observe specialists. The diagnosis of a hemangioma of the liver does not require sharp changes in a person's life. The expediency of the operation or other methods of treatment should be discussed with a specialist.