a hemangioma can rarely be pedunculated ; as a result , it may undergo torsion and infarction , which can make it symptomatic .
we report the case of a 45-year - old woman with acute abdominal pain due to torsion of a giant pedunculated hepatic hemangioma around its vascular stalk .
pedunculated hemangioma of the liver is an uncommon benign tumor , a rare differential diagnosis for a mass located in the upper abdomen .
all incidentally detected pedunculated hemangiomas must be surgically managed , as these have a tendency to become torsioned , and there is also a risk of malignancy or rupture .
hemangioma is the most common benign tumor of the liver , with an autopsy prevalence of 0.4% - 20% .
women are more often affected , at a ratio of 5:1 - 6:1 ( 1 , 2 ) . hemangiomas can occur at any age , are usually solitary , and are found more commonly in the right lobe , especially in the posterior segment ( 3 ) .
liver hemangiomas are asymptomatic in most cases , and are commonly detected incidentally by imaging modalities such as ultrasonography , ct , or mri ( 4 ) .
hepatic hemangiomas are usually < 3 cm in diameter , and those measuring > 4 cm are classified as giant ( 5 ) .
giant hemangiomas can become large enough to cause symptoms due to mass effect on the abdominal viscera , abdominal pain , discomfort , hemorrhage , jaundice , and nausea ( 5 - 8 ) .
exophytic forms of hepatic hemangiomas , especially pedunculated forms , are extremely rare , with only a few cases reported in the literature ( 9 , 10 ) .
this case study is a report of a patient with a giant pedunculated hepatic hemangioma , who was referred to the emergency ward with acute abdominal pain due to torsion of the hemangioma around its vascular stalk .
a 45-year - old woman with acute abdominal pain presented to the emergency ward of a private general hospital in babol , northern iran , on may 4 , 2015 .
her pain had originated in the epigastrium and had an incremental trend for two days prior to her admission .
she had also experienced nausea , vomiting , and loss of appetite during that time . the patient had a history of chronic abdominal discomfort and upper gastrointestinal bleeding ( ugib ) due to gastritis .
she also reported that she had taken oral contraceptive pills ( ocps ) for approximately 5 years , many years earlier . on examination ,
her vital signs were all normal : blood pressure 125/75 mmhg , pulse rate 78 beats / min , respiratory rate 18 breaths / min , and oral temperature 37.3c .
there was a mild generalized tenderness , as well as severe tenderness in the upper part of the abdomen , prominently the epigastrium , but there was no rebound tenderness or guarding .
complete blood count , basic metabolic profile , coagulation tests , and liver function tests were all within normal limits .
there were no abnormal findings on the upright chest film and abdominal x - ray .
ultrasonography revealed a 92  42  72 mm solid ovoid mass with exophytic features , originating from the anterior border of the left lobe of the liver .
abdominopelvic ct scan with contrast media demonstrated a 100  64 mm lobulated oval mass showing central necrosis in the anterior aspect of the abdomen , suggesting a mesenteric mass lesion , such as gastrointestinal stromal tumor ( gist ) , as the first differential diagnosis . due to her past history of ugib
, she underwent esophagogastroduodenoscopy by a gastroenterologist , and no mass or ulcer was observed . however , there was mass effect , most probably gastric compression due to an extragastric mass lesion , with a remote possibility of a submucosal lesion .
, she had a low - grade fever and decreased hemoglobin ( from 10 to 8.3 g / dl ) . according to the clinical and paraclinical findings , the unknown etiology of the mass , the possibility of malignancy , and the risks of bleeding and hemoperitoneum
, we decided to perform surgical management .   in the operating room , under general anesthesia ( ga ) and with full monitoring in the supine position ,
a large , multilobulated , dark red mass was discovered attached to the anterior edge of the left lobe of the liver by a vascular pedicle .
macroscopically , it measured 10.5  8.8  7 cm and weighed 316 g. the histopathological analysis confirmed a huge pedunculated hepatic hemangioma , with marked vascular congestion and focal hemorrhagic infarct , with no evidence of atypia .
she was discharged from the hospital three days after surgery ( figures 1 - 3 ) .
cavernous hemangioma is the most common benign tumor of the liver , probably with a congenital origin , and there is no potential for malignant transformation ( 1 ) .
it predominates in females 5:1 to 6:1 , and is most common from age 30 to 50 years .
it is usually discovered incidentally on imaging modalities such as ultrasonography , ct , and mri ( 2 ) .
these tumors can measure from a few millimeters up to 20 cm in size , and are commonly classified as giant if they measure > 4 cm in diameter ( 1 ) .
a pedunculated hemangioma can extend beyond the border of the liver ( 2 ) , but giant pedunculated hemangiomas , as in the present case , are very rare ( 11 - 13 ) .
a good illustration of this is our patient , who experienced abdominal distention and a mass , abdominal pain , early satiety , nausea , vomiting , icterus , and thrombocytopenia ( 1 , 6 , 10 , 14 ) .
the first reported case of a giant pedunculated hepatic hemangioma was by ellis et al . in 1985 ( 3 ) .
another study reported a total of 24 cases of pedunculated , exophytic hemangiomas , which was consistent with the existing literature up to the year 2008 ( 2 , 9 ) .
pedunculated hepatic hemangiomas are sometimes mistaken for other pedunculated tumors , such as hepatocellular carcinoma , hamartoma , focal nodular hyperplasia , and adenoma ( 3 ) .
our patient had a history of ocp use , which could increase the incidence of adenoma .
however , if the hemangioma is large or giant and pedunculated , it can cause mass effect , abdominal symptoms , and a potential risk of rupture ( 2 ) . very rarely , these hemangiomas can spontaneously rupture with intra - abdominal hemorrhage , which may also occur due to blunt trauma , creating acute abdominal symptoms . for this condition , surgery is the best treatment choice , especially for a giant symptomatic hemangioma with an uncertain diagnosis .
a giant pedunculated hemangioma may undergo torsion around its pedicle , as in our case , and can become infracted , thereby becoming symptomatic .
pain is the most frequent symptom , which is due to infarction or pressure on the adjacent organs ( 1 ) .
torsion of a giant pedunculated hemangioma is extremely rare , and had not been reported more than once in the literature up to the year 2010 .
as the majority of hemangiomas are asymptomatic , they do not require treatment . in symptomatic cases ,
the indications for surgical intervention include a palpable mass , rapid growth , thrombocytopenia , and rupture with intraperitoneal bleeding pain or epigastric discomfort , as demonstrated in our patient ( 4 ) . in the present case , we decided to perform surgical treatment after considering the symptoms , the large diameter of the mass , the inability to exclude malignancy , and the risk of rupture of the lesion .
if surgery is contraindicated , other treatment modalities , such as radiation therapy , hepatic artery ligation , and arterial embolization can be used ( 10 ) . in conclusion ,
pedunculated hemangiomas of the liver are uncommon benign tumors that should be included in the differential diagnosis of any mass located in the upper abdomen .
imaging modalities , such as ultrasound , ct , mri , radionuclide scintigraphy , and angiography , may be used to diagnose these tumors .
this case report and other similar studies indicate that all incidentally detected pedunculated hemangiomas must be surgically managed , as they have a tendency to become torsioned .
in conclusion , pedunculated hemangiomas of the liver are uncommon benign tumors that should be included in the differential diagnosis of any mass located in the upper abdomen .
imaging modalities , such as ultrasound , ct , mri , radionuclide scintigraphy , and angiography , may be used to diagnose these tumors . this case report and other similar studies
indicate that all incidentally detected pedunculated hemangiomas must be surgically managed , as they have a tendency to become torsioned .
 introductionhemangioma is the most common benign tumor of the liver . 
 most cases are asymptomatic and do not require treatment . 
 a hemangioma can rarely be pedunculated ; as a result , it may undergo torsion and infarction , which can make it symptomatic.case presentationwe report the case of a 45-year - old woman with acute abdominal pain due to torsion of a giant pedunculated hepatic hemangioma around its vascular stalk.conclusionspedunculated hemangioma of the liver is an uncommon benign tumor , a rare differential diagnosis for a mass located in the upper abdomen . 
 all incidentally detected pedunculated hemangiomas must be surgically managed , as these have a tendency to become torsioned , and there is also a risk of malignancy or rupture . 
Introduction
Case Presentation
Conclusions
1. Introduction
2. Case Presentation
3. Discussion
3.1. Conclusions