Hepatic Hemangioma Research Articles

Spontaneous evolution patterns of focal congenital hepatic hemangiomas: a case series of 25 patients.

Hepatic hemangiomas are the most common benign liver tumors of infancy. They are termed congenital if fully developed at birth or infantile if they appear in the first weeks of life. Previous studies suggested that most focal hepatic hemangiomas are congenital in nature, exhibit no postnatal growth and have an evolution that parallels their cutaneous counterparts. They are subdivided by pattern of involution, whether rapidly involuting (RICH), partially involuting (PICH) or non-involuting (NICH) congenital hemangiomas. In our experience, some focal hepatic hemangiomas show postnatal growth, behaving like infantile forms. To analyze the spontaneous evolution of focal congenital hepatic hemangiomas with quantification of tumor volume changes over time and to identify initial postnatal ultrasound (US) imaging biomarkers predictive of their evolution pattern. A retrospective review of clinical, imaging and pathology data of children diagnosed with focal congenital hepatic hemangioma (prenatal diagnosis or age at diagnosis <7days and/or glucose transporter protein 1 [GLUT1]-negative tumor) diagnosed between 2000 and 2018 was performed with analysis of tumor volume changes over time. Exclusion criteria were treatment inducing a tumor volume change (hepatic artery embolization, propranolol, or corticosteroids), imaging follow-up less than 1month or fewer than two US examinations. Volumetric analysis was based on US and cross-sectional imaging. Lesion volumes were estimated using the standard ellipsoid formula. A 35% margin of error was assumed for tumor volume variation to account for variability in measurements. Imaging studies, including US, computed tomography, and magnetic resonance imaging, were reviewed and initial postnatal US features were correlated with evolution pattern. Twenty-five patients with focal congenital hepatic hemangiomas were included. The median follow-up time was 46.5months (range: 4-144months). Eight (32%) lesions showed postnatal growth before involuting, without signs of intralesional hemorrhage, as do cutaneous infantile hemangiomas. The other 17 (68%) lesions exhibited a strict decrease in volume with age, of which 15 underwent complete involution (8 before age 18months and 7 after age 18months) and 2 underwent partial involution. The different evolution patterns of focal congenital hepatic hemangiomas showed overlapping imaging features and we found no initial US feature to be significantly associated with postnatal growth. However, large vascular spaces with marked vascularity at US were noted in three of the eight rapidly involuting lesions. Focal congenital hepatic hemangiomas are not the equivalent of cutaneous RICH, as some may increase in size and tumor regression may be rapid or slow. The different evolution patterns of focal congenital hepatic hemangiomas show overlapping US features.

Rare Case of Cavernous Haemangioma of the Right Atrium with Probable Hepatic Haemangioma

Cardiac haemangiomas are rare causes of atrial masses. This case report is of a 44-year-old male who presented with a right atrial mass that was found incidentally on a CT performed for renal colic. The mass was further investigated with a transthoracic echocardiogram that showed that it was echodense and arising from the Eustachian valve in the right atrium. Coronary angiogram revealed large well-developed atrial branches that crossed superiorly over the left atrium and entered the mass in the right atrium. Surgical resection was undertaken, and this confirmed that the mass had a fleshy, encapsulated appearance with a sessile stalk. Histology demonstrated a cavernous haemangioma. The patient had a residual small defect in the interatrial septum postoperatively but otherwise made a good recovery.

Infantile hepatic hemangiomas: looking backwards and forwards.

Infantile hepatic hemangiomas (IHHs) are common benign tumors seen in the liver of infants. IHHs are true infantile hemangiomas (IHs) and have phases of proliferation and involution parallel to those of cutaneous IHs. The definition and classification of IHH are still confusing in the literature. The mechanisms during the pathogenesis of IHH have yet to be discovered. The clinical manifestations of IHH are heterogeneous. Although most IHH lesions are asymptomatic, some lesions can lead to severe complications, such as hypothyroidism, consumptive coagulopathy, and high-output congestive cardiac failure. Consequently, some patients can possibly encounter a fatal clinical condition. The heterogeneity of the lesions and the occurrence of disease-related comorbidities can make the treatment of IHH challenging. Oral propranolol is emerging as an effective systemic approach to IHH with obvious responses in tumor remission and symptom regression. However, the precise clinical characteristics and treatment strategies for patients with severe IHH have not yet been well established. Here, we summarize the epidemiology, pathogenic mechanism, clinical manifestations, diagnosis, and treatment of IHH. Recent updates and future perspectives for IHH will also be elaborated.

Presentation of Congenital Portosystemic Shunts in Children.

Background: Congenital portosystemic shunts (CPSS) are rare vascular anomalies resulting in communications between the portal venous system and the systemic venous circulation, affecting an estimated 30,000 to 50,000 live births. CPSS can present at any age as a multi-system disease of variable severity mimicking both common and rare pediatric conditions. Case presentations: Case A: A vascular malformation was identified in the liver of a 10-year-old girl with tall stature, advanced somatic maturation, insulin resistance with hyperinsulinemia, hyperandrogenemia and transient hematuria. Work-up also suggested elevated pulmonary pressures. Case B: A young girl with trisomy 8 mosaicism with a history of neonatal hypoglycemia, transient neonatal cholestasis and tall stature presented newly increased aminotransferase levels at 6 years of age. Case C: A 3-year-old boy with speech delay, tall stature and abdominal pain underwent abdominal ultrasound (US) showing multiple liver nodules, diagnosed as liver hemangiomas by hepatic magnetic resonance imaging (MRI). Management and outcome: After identification of a venous malformation on liver Doppler US, all three patients were referred to a specialized liver center for further work-up within 12 to 18 months from diagnosis. Angio-computed tomography (CT) scan confirmed the presence of either an intrahepatic or extrahepatic CPSS with multiples liver nodules. All three had a hyperintense signal in the globus pallidus on T1 weighted cerebral MRI. Right heart catheterization confirmed pulmonary hypertension in cases A and C. Shunts were closed either using an endovascular or surgical approach. Liver nodules were either surgically removed if there was a risk of malignant degeneration or closely monitored by serial imaging when benign. Conclusion: These cases illustrate most of the common chief complaints and manifestations of CPSS. Liver Doppler US is the key to diagnosis. Considering portosystemic shunts in the diagnostic work-up of a patient with unexplained endocrine, liver, gastro-intestinal, cardiovascular, hematological, renal or neurocognitive disorder is important as prompt referral to a specialized center may significantly impact patient outcome.

Interventional treatments for hepatic hemangioma: A state-of-the-art review

Hepatic hemangiomas (HHs) are the most common benign tumors of the liver. These tumors are mainly asymptomatic and do not require treatment. Nevertheless, there are some special cases that require therapeutic intervention, and surgery and intervention are currently the primary treatment modalities. Despite significant advances in the development of minimally invasive techniques and their popularization, interventional treatment of HH is still the preferred choice. In the present review, we discuss the pathological properties, type of blood supply, and treatment indications for HH and assess the status and progress of the existing interventional treatments.

Safety and efficacy of microwave versus radiofrequency ablation for large hepatic hemangioma: a multicenter retrospective study with propensity score matching

To compare the safety and efficacy of microwave ablation (MWA) and radiofrequency ablation (RFA) for such hemangiomas (5-9.9cm in diameter). This multicenter retrospective cohort study investigated the differences in technical success, ablation time, complete ablation, complications, hospital stay, and clinical response between MWA and RFA. A total of 452 patients with hepatic hemangiomas were screened. Propensity score matching was performed. Univariable and multivariate regression analyses were used. Among the 452 patients, 394 met the eligibility criteria and completed the follow-up. After the propensity score matching analysis, 72 pairs of patients were created. No technical failures were found. The RFA group had a longer ablation time (48.63 ± 18.11min versus [vs.] 37.18 ± 15.86min, p < 0.001), higher morbidity of hemoglobinuria (77.78% vs. 50.00%, p < 0.001), and longer hospital stay (5.01 ± 1.56days vs. 4.34 ± 1.42days, p < 0.05) than the MWA group. The treatment methods (p = 0.032, OR = 0.105, 95% CI = 0.013-0.821), size of the hemangioma (p = 0.021, OR = 5.243, 95% CI = 1.285-21.391), and time of ablation (p = 0.031, OR = 1.145, 95% CI = 1.013-1.294) were significant independent risk factors associated with hemoglobinuria. No recurrence or delayed complications were observed. There were no differences in complete ablation, clinical response, and health-related quality of life between the groups. MWA and RFA appear to be effective treatments for large hepatic hemangiomas. However, MWA had a shorter ablation time than RFA, and MWA was associated with fewer hemolysis-related complications and shorter hospital stays. • MWA and RFA appear to be effective treatments for large hepatic hemangiomas. • MWA had a shorter ablation time than RFA. • MWA was associated with fewer hemolysis-related complications and shorter hospital stays.

Perfusion-Diffusion Ratio: A New IVIM Approach in Differentiating Solid Benign and Malignant Primary Lesions of the Liver.

Introduction In order to improve the efficacy of intravoxel incoherent motion (IVIM) parameters in characterising specific tissues, a new concept is introduced: the perfusion–diffusion ratio (PDR), which expresses the relationship between the signal S(b) decline rate as a result of IVIM and the rate of signal S(b) decline due to diffusion. The aim of this study was to investigate this novel approach in the differentiation of solid primary liver lesions. Material and Methods. Eighty-three patients referred for liver MRI between August 2017 and January 2020 with a suspected liver tumour were prospectively examined with the standard liver MRI protocol extended by DWI-IVIM sequence. Patients with no liver lesions, haemangiomas, or metastases were excluded. The final study population consisted of 34 patients with primary solid liver masses, 9 with FNH, 4 with regenerative nodules, 10 with HCC, and 11 with CCC. The PDR coefficient was introduced, defined as the ratio of the rate of signal S(b) decrease due to the IVIM effect to the rate of signal S(b) decrease due to the diffusion process, for b = 0. Results No significant differences were found between benign and malignant lesions in the case of IVIM parameters (f, D, or D∗) and ADC. Significant differences were observed only for PDR, with lower values for malignant lesions (p = 0.03). The ROC analysis yielded an AUC value for PDR equal to 0.74, with a cut-off value of 5.06, sensitivity of 81%, specificity of 77%, and accuracy of 79%. Conclusion PDR proved to be more effective than IVIM parameters and ADC in the differentiation of solid benign and malignant primary liver lesions.

Morphological, dynamic and functional characteristics of liver pseudolesions and benign lesions.

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide and one of the most common causes of death among patients with cirrhosis, developing in 1-8% of them every year, regardless of their cirrhotic stage. The radiological features of HCC are almost always sufficient for reaching the diagnosis; thus, histological confirmation is rarely needed. However, the study of cirrhotic livers remains a challenge for radiologists due to the developing of fibrous and regenerative tissue that cause the distortion of normal liver parenchyma, changing the typical appearances of benign lesions and pseudolesions, which therefore may be misinterpreted as malignancies. In addition, a correct distinction between pseudolesions and malignancy is crucial to allow appropriate targeted therapy and avoid treatment delays.The present review encompasses technical pitfalls and describes focal benign lesions and pseudolesions that may be misinterpreted as HCC in cirrhotic livers, providing the imaging features of regenerative nodules, large regenerative nodules, siderotic nodules, hepatic hemangiomas (including rapidly filling and sclerosed hemangiomas), segmental hyperplasia, arterioportal shunts, focal confluent fibrosis and focal fatty changes. Lastly, the present review explores the most promising new imaging techniques that are emerging and that could help radiologists differentiate benign lesions and pseudolesions from overt HCC.

HEPATIC VASCULAR TUMORS IN CHILDREN: POTENTIAL RISKS, OPTIMAL IMAGING AND THE ROLE OF SURGICAL INTERVENTION.

The aim: To revise the case-series of hepatic vascular tumors (HVT), particularly to identify optimal visualization, management and role of surgical intervention. Materials and methods: Out of 96 children with hepatic tumors who hospitalized in a single center from 2011 to 2020, 20 (20,8%) were diagnosed HVT. Hepatic Hemangiomas (HHs) were presented in 19 patients and Kaposiform hemangioendotelioma (KHE) in one case. To determine the type of HH we used radiological classification. For visualisation contrast-enhanced MRI (n=7, 30%) and cCT (n=15,70%) were used. Follow-up period was 14-77 months. Results: All HVT were revealed by sonogram at the age of 0-5 m, with 4 (20%) diagnosed prenatally. Male to female ratio was 3:2. Beta-blockers were prescribed to 12 patients with HHs. Treatment duration was from 6 to 24 month. Steroid therapy was initial in cases when it was impossible to prescribe the curative dose of beta-blockers. Complications of propranolol treatment were transitory bradycardia (n=7) and transitory hypoglycemia (n=2). After vincristine chemotherapy decreases the tumor size by 54%, that allowed a safe liver resection. 4 (20%) patients - two multifocal HHs, one diffuse HH and in patient with KHE manifested congestive heart failure and pulmonary hypertension Mortality rate is 5% (n=1), this patient died against progressive cardiovascular failure. Conclusions: life-threatening complication of HVT was congestive heart failure. Early treatment is beneficial for complications prevention. Surgical treatment is optional for KHE when can be removed safely.

Comparison of Hepatectomy and Hemangiomas Stripping on Patients with Giant Hepatic Hemangiomas.

Objective To compare the value of a hepatectomy and hemangioma stripping on patients with giant hepatic hemangiomas. Methods Seventy-four patients with giant hepatic hemangiomas were retrospectively analyzed from data collected from their hepatobiliary surgeries performed from June 2010 to June 2015 at the People's Hospital of Ningxia and the general hospital affiliated with Ningxia Medical University. The patients were divided into a hepatectomy group (37 patients) and a hemangioma-stripping group (37 patients). Conditions of each group were compared before and after surgery and comprised of surgery duration, intraoperative blood loss, blood transfusion, duration of hepatic blood occlusion, and hospital stay. Any complications after surgery, such as pleural effusions, bile leakage, and abdominal hemorrhage, were also observed. Results In the hemangioma-stripping group, the surgery time was 2.38 ± 0.93 h, intraoperative blood loss was 889.19 ± 756.37, blood transfusion amount was 723.78 ± 801.14, the duration of hepatic blood occlusion 26.84 ± 17.30 min, and hospital stay was 16.19 ± 5.01 d. In the hepatectomy group, surgery time was 3.26 ± 1.16 h, intraoperative blood loss was 1551.35 ± 1755.88 mL blood transfusion amount was 1693.24 ± 2117.72 mL, duration of hepatic blood occlusion was 26.84 ± 17.30 min, and hospital stay was 16.19 ± 5.01 d. The difference between the groups was statistically significant (P < 0.05). The pleural effusion incident rate in the former group was lower than that of the latter group, and the difference was statistically significant. Conclusions Hemangiomas stripping is an effective method by which to cure hepatic hemangioma, with the advantages being a relatively easy surgery with less patient trauma, rapid recovery, and fewer complications. This method should be used more often in clinical settings.

Radiomics Analysis on Noncontrast CT for Distinguishing Hepatic Hemangioma (HH) and Hepatocellular Carcinoma (HCC).

Background To form a radiomic model on the basis of noncontrast computed tomography (CT) to distinguish hepatic hemangioma (HH) and hepatocellular carcinoma (HCC). Methods In this retrospective study, a total of 110 patients were reviewed, including 72 HCC and 38 HH. We accomplished feature selection with the least absolute shrinkage and operator (LASSO) and built a radiomics signature. Another improved model (radiomics index) was established using forward conditional multivariate logistic regression. Both models were tested in an internal validation group (38 HCC and 21 HH). Results The radiomic signature we built including 5 radiomic features demonstrated significant differences between the hepatic HH and HCC groups (P < 0.05). The improved model demonstrated a higher net benefit based on only 2 radiomic features. In the validation group, radiomics signature and radiomics index achieved great diagnostic performance with AUC values of 0.716 (95% confidence interval (CI): 0.581, 0.850) and 0.870 (95% CI: 0.782, 0.957), respectively. Conclusions Our developed radiomics-based model can successfully distinguish HH and HCC patients, which can help clinical decision-making with lower cost.

Right Hepatectomy for Giant Liver Hemangioma Guided with Intraoperative Ultrasound and Indocyanine Green

Background: Hepatic hemangiomas are benign vascular tumors of the liver, most of them asymptomatic. Surgical management includes enucleation, embolization, and liver resection. We present a case with symptomatic hepatic hemangioma susceptible to surgical treatment. Case Presentation: A 73-year-old man with chronic obstructive pulmonary disease and a history of two small hemangiomas started with pain in the right upper quadrant. Computerized tomography showed multiple hypodense lesions highly suggestive of hepatic hemangioma. Tumor markers were found at normal levels. A right hepatectomy guided with indocyanine green and intraoperative ultrasound was performed minimal bleeding and pulmonary complications. Conclusion: Hepatectomy for giant hemangiomas combined with ultrasound and indocyanine green is a feasible option in patients with comorbidities, decreasing bleeding risk, and allowing complete and surgical resection.

Frequency of Living Donors with Comorbidity for Liver Transplantation: Analysis of 337 Cases

Introduction: Living donors for liver transplantation (LT) need to be physically and mentally healthy, but donor candidates sometimes have comorbidities and are forced to evaluate the suitability as donors. We examined the frequency of comorbidities in living liver donors. Patients and methods: Of 337 living donors for LT, except 67 cases with fatty liver, we investigated the preoperative comorbidities and perioperative management in living liver donors. Results: The number of donors with comorbidity was 95 (28%: 95/337), with a median age of 35 (23-57) years, 33 males, and 62 females. Relationships with recipients were 58 mothers, 28 fathers, 2 grandmothers, 2 sons, 5 others. The graft types were 62 lateral segments, 15 left lobes, 6 left lobes with caudate, 6 monosegments, 4 right lobes, and 2 posterior segments. A total of 107 comorbidities was recognized in 95 donors. Twenty-two cases with hepatic comorbidity were positive HBc antibodies, hepatic hemangiomas, drug-induced liver injuries, liver hamartoma, and congenital portosystemic shunt. Extrahepatic comorbidities were plasminogen disorder, obstructive respiratory disorder, lipid metabolism disorder, coagulation factor deficiency, iron deficiency anemia, hypertension, pollinosis, thyroid disease, menstrual abnormalities, postoperative gastrointestinal cancer, metabolic disease, benign ovarian tumor, arrhythmia, pregnancy, and others. We consulted with the department specializing in the comorbidity and closely performed preoperative evaluation and perioperative management according to each comorbidity. No case of complications due to each comorbidity was found. Conclusion: It is important to fully evaluate and determine the suitability of living donor candidates with comorbidities in collaboration with other departments.

Alterations of actin cytoskeleton and arterial protein level in patients with obstructive jaundice.

Vascular hypo-responsiveness to vasopressors in patients with obstructive jaundice (OJ) is a common anesthetic event, which leads to perioperative complications and increased mortality. The cause of this clinical issue remains unclear. In this study, we estimated the actin cytoskeleton and arterial protein level in the artery of OJ patients by proteomic analysis. Ten patients with OJ due to bile duct diseases or pancreatic head carcinoma were enrolled, while another ten non-jaundice patients with chronic cholecystitis or liver hemangioma as the control group. Vascular reactivity to noradrenaline was measured before anesthesia on the day of surgery. Artery samples in adjacent tissues of removed tumor were collected and evaluated by 2-dimensional electrophoresis. Proteins with differential expression were detected by MALDI-TOF mass spectrometry with immunoblot confirmation. The results confirmed the phenomenon of vascular hypo-reactivity in OJ patients as suppressed aortic response to noradrenaline were existed in these patients. We also found that actin cytoskeleton and several actin-binding proteins were up- or down-regulated in the artery of OJ patients. These proteins changed in OJ patents might be the basic mechanism of vascular hypo-reactivity, further studies to uncover the role of these proteins in OJ is critical for clinical treatment of these patients.

Hepatic Cavernous Hemangioma: When Should it Be Resected?

Introduction: Hepatic cavernous hemangioma (HCH) is a congenital vascular malformation and is the most frequent solid hepatic benign tumor. Because the use of cross-sectional imaging studies HCH are frequently encountered. Surgeons have to be familiar with the appropriated diagnostic method, management and outcome. The aim of this presentation is to assess surgical indications and outcomes of resected patients.

Morbidity Analysis of Left Hepatic Trisectionectomy for Hepatobiliary Disease and Live Donor

Introduction: Despite remarkable advances in surgical techniques and perioperative management, left hepatic trisectionectomy (LHT) remains a challenging procedure with a somewhat higher postoperative morbidity compared with less-extensive resections. The aims of this study were to analyze the short- and long-term outcomes of LHT and to identify factors associated with postoperative morbidity of this technically demanding surgical procedure. Method: The medical records of 52 patients who underwent LHT between June 2005 and October 2019 at a single institution were retrospectively reviewed. Results: Hepatocellular carcinoma was the most common indication for surgery (n=21), followed by hilar cholangiocarcinoma (n=14), intrahepatic cholangiocarcinoma (n=9), and other pathologies (including colorectal liver metastasis, hepatolithiasis, gallbladder cancer, living donor, hemangioma, and multilocular biliary cyst; n=8). The rates of postoperative morbidities of Clavian-Dindo grade 3 or higher and 90-day mortality were 38.5% and 1.9%, respectively. The overall 1-,3-,and 5-year survival rates were 80.8%, 62.6%, and 45.5%, respectively. Preoperative portal vein embolization (p=0.017), an American Society of Anesthesiologists fitness grade > II (p=0.008), operation time (p=0.014), extent of surgery by concomitant extrahepatic bile duct resection (p=0.043) and lymphadenectomy (p=0.005), and the number of tumors (p=0.012) were independent predictors of postoperative morbidity on multivariable analysis. Conclusions: The success of LHT is dependent on a reliable preoperative evaluation of liver function and the anatomic features of right posterior portal vein variants and hepatic veins toward the posterior sector, active and appropriate preoperative management for obstructive cholangitis and compensatory hypertrophy of the future remnant posterior sector, and the experience of the surgeon.

A Case of Giant Hepatic Hemangioma (23 cm in Long Diameter) with Severe Malnutrition and Blood Coagulopathy

症例は40歳の女性で，1カ月前から増悪する腹部膨満と右側腹部痛および経口摂取不良のため，近医を受診した．腹部超音波検査で肝右葉を占める巨大肝腫瘍を指摘され，当院へ紹介となった．長期間の経口摂取不良のため重度低栄養状態であり，血液検査にて高度の貧血，フィブリノーゲン値低下，FDPとDダイマー値の著明な上昇を認めた．腹部造影CTと造影MRIから，腫瘍内出血を伴う23×15cmの巨大肝海綿状血管腫と診断した．腫瘍随伴性の栄養障害と凝固機能異常をきたしており，手術適応と判断した．術中の出血コントロール目的に腫瘍の支配血管である右肝動脈に対する塞栓術を術前に施行し，肝右3区域切除術を施行した．術後凝固異常の著明な改善を認め，経口摂取も良好となり，経過良好にて術後11日目に退院となった．術後12カ月現在，血液検査の正常化および栄養状態の改善を認め，無再発経過観察中である．

Study Protocol for a Multicenter Nationwide Prospective Cohort Study to Investigate the Natural Course and Clinical Outcome in Benign Liver Tumors and Cysts in The Netherlands: The BELIVER Study

Introduction: Benign liver tumours and cysts (BLTCs) comprise a heterogeneous group of cystic and solid lesions, including hepatic hemangioma, focal nodular hyperplasia and hepatocellular adenoma. Some BLTCs, for example (large) hepatocellular adenoma, are at risk of complications. Incidence of malignant degeneration or hemorrhage is low in most other BLTCs. Nevertheless, the diagnosis BLTC may carry a substantial burden and patients may be symptomatic, necessitating treatment. The indications for interventions remain matter of debate. The primary study aim is to investigate patient reported outcomes (PROs) of patients with BLTCs, with special regard to the influence of invasive treatment as compared to the natural course of the disease. Methods and analysis: A nationwide observational cohort study of BLTC patients will be performed between August 2021 and August 2026. Inclusion will be open from August 2021 until August 2025. During surveillance, a questionnaire regarding symptoms and their impact will be sent to participants on a biannual basis and more often in case of invasive intervention. The questionnaire was previously developed based on patient reported outcomes (PROs) considered relevant to patients with BLTCs and their caregivers. Most questionnaires will be administered by computerized adaptive testing through the Patient-Reported Outcomes Measurement Information System (PROMIS). Data, such as treatment outcomes, will be extracted from electronic patient files. Multivariable analysis will be performed to identify patient and tumour characteristics associated with significant improvement in PROs or a complicated postoperative course.

Evaluation of hepatic hemangioma in patients with cherry angioma

Evaluation of hepatic hemangioma in patients with cherry angioma

One stop shop approach for the diagnosis of liver hemangioma.

Hepatic hemangioma is usually detected on a routine ultrasound examination because of silent clinical behaviour. The typical ultrasound appearance of hemangioma is easily recognizable and quickly guides the diagnosis without the need for further investigation. But there is also an entire spectrum of atypical and uncommon ultrasound features and our review comes to detail these particular aspects. An atypical aspect in standard ultrasound leads to the continuation of explorations with an imaging investigation with contrast substance [ultrasound/ computed tomography/or magnetic resonance imaging (MRI)]. For a clinician who practices ultrasound and has an ultrasound system in the room, the easiest, fastest, non-invasive and cost-effective method is contrast enhanced ultrasound (CEUS). Approximately 85% of patients are correctly diagnosed with this method and the patient has the correct diagnosis in about 30 min without fear of malignancy and without waiting for a computer tomography (CT)/MRI appointment. In less than 15% of patients CEUS does not provide a conclusive appearance; thus, CT scan or MRI becomes mandatory and liver biopsy is rarely required. The aim of this updated review is to synthesize the typical and atypical ultrasound aspects of hepatic hemangioma in the adult patient and to propose a fast, non-invasive and cost-effective clinical-ultrasound algorithm for the diagnosis of hepatic hemangioma.