A 32-year-old male patient presented to the emergency department with giant painful hepatomegaly accompanied by abdominal distension.
Among its antecedents there is a surgical intervention in Morocco of a hepatic hemangioma a year and a half ago, of which we have no more information.
No other relevant medical or family history.
The patient has a normal baseline for his age.
Physical examination revealed blood pressure of 140/70, heart rate of 72 bpm and temperature of 36.5oC.
He has a systolic murmur in the mitral area, pulmonary auscultation with normal vesicular murmur and an abdomen distended with great painful hepatohepatitis that reaches both iliac fossae without palpable normal stenosis and peristalsis.
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Analytical data revealed a haemoglobin of 10.4 g/dl, haematocrit 32.5%; MCV 82; MU 26.3 pg; platelets 144 x 103/μl; serum leukocytes 83GT /ul (N:
Total bilirubin 1.5 mg/dl; direct bilirubin: 1 mg/dl. Creatinine 0.93 mg/dl. Normal ions and amylase.
Serology for hepatitis B, C, HIV and LUES negative.
The coagulation study showed a prothrombin activity of 52%, a compatible DI exceed 2,500 ng/ml, TT of 38 seconds, fibrin of 53 mg/dl, and 57% with functional Karit syndrome.
The chest X-ray showed an elevation of both hemidiaphragms secondary to hepatomegaly, without cardiomegaly or pulmonary infiltrates.
A large hepatomegaly displacing intestinal loops to the left iliac fossa was observed in the simple abdomen.
Echocardiogram with a structurally and functionally normal heart, except for compression of the right cavities due to hepatomegaly that does not cause hemodynamic compromise.
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After his arrival to the emergency department, taking into account his antecedents, it was decided to perform abdominal CT to assess bleeding secondary to traumatic rupture of the hemangioma, observing: very enlarged liver with heterogeneous density, with multiple peripheral nodular images of hypoden.
He also had a large tail-dependent hypodense mass, with a lobulated appearance, of a size of approximately 17 x 7 cm (T x AP), with a pattern of contrast uptake similar to those of the intestinal pancreas as above.
Small amount of free fluid in Douglas
All this is suggestive of hepatic hemangioma.
Hepatic parenchyma seems to be respected at segment VII.
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These findings were correlated with ecchymosis confirming the diagnostic suspicion of multiple hepatic hemangioma with giant hemangioma of 17 x 7 cm and ascites.
The suspicion of traumatic rupture of the same and due to the hemodynamic and analytical stability of the patient, it was decided to perform CT angiography to assess the presence of active bleeding that ruled out active embolization.
Compression of the left renal vein was evident, with formation of collateral vessels to the retroperitoneum.
Therefore, we confirmed the diagnosis of giant hepatic hemangioma with hemangiomatosis and associated Kasabach-Merritt syndrome.
