Guideline sources The following summarized guidelines for the evaluation and management of hepatic hemangioma are prepared by our editorial team based on guidelines from the American College of Radiology (ACR 2020), the European Federation of Societies for Ultrasound (EFSU 2020), the European Association for the Study of the Liver (EASL 2016), and the American College of Gastroenterology (ACG 2016; 2014). 1 2 3 4 5 Guidelines 1. Diagnostic investigations Contrast-enhanced ultrasound: As per ACR 2020 guidelines: Obtain contrast-enhanced abdominal ultrasound of an indeterminate > 1 cm liver lesion on initial ultrasound in patients with a normal liver with no suspicion or evidence of extrahepatic malignancy or underlying liver disease. B Obtain contrast-enhanced abdominal ultrasound of an incidental liver lesion > 1 cm on initial ultrasound, non-contrast or single-phase CT, or non-contrast MRI in patients with known chronic liver disease. B https://web.pathway.md/diseases/recZPcRcjiO2GFdbJ 1/3 6/24/23, 12:41 PM Hepatic hemangioma Pathway As per EFSU 2020 guidelines, obtain liver ultrasound using B-mode and Doppler mode before obtaining contrast-enhanced ultrasound to characterize focal liver lesions. B Show 14 more As per EASL 2016 guidelines: Obtain contrast-enhanced imaging (such as contrast-enhanced ultrasound) in patients with an oncological condition or an underlying liver disease. B Confirm the diagnosis with contrast-enhanced imaging based on a typical vascular profile characterized by peripheral and globular enhancement in the arterial phase followed by a central enhancement in the delayed phases. B Cross-sectional imaging: As per ACR 2020 guidelines, obtain contrast-enhanced multiphase CT, contrast-enhanced MRI, or contrast-enhanced ultrasound of an indeterminate > 1 cm liver lesion on initial ultrasound in patients with a normal liver with no suspicion or evidence of extrahepatic malignancy or underlying liver disease. B Show 7 more As per EASL 2016 guidelines, suspect hepatic hemangioma in the presence of a hyperechoic lesion in patients with a normal and healthy liver. Obtain ultrasound to confirm the diagnosis with typical imaging features (homogeneous hyperechoic, sharp margin, posterior enhancement, and absence of halo sign) in a lesion < 3 cm. B Show 2 more As per ACG 2014 guidelines, obtain MRI or CT for the diagnosis of hepatic hemangioma. B 2. Diagnostic procedures Liver biopsy: avoid performing a liver biopsy in the presence of radiologic features suggestive of hepatic hemangioma. D 3. Medical management Indications for treatment: As per EASL 2016 guidelines, offer conservative management in patients with typical cases of hepatic hemangioma. B As per ACG 2014 guidelines, do not offer any intervention for asymptomatic hepatic hemangiomas regardless of size. D 4. Specific circumstances Pregnant patients: do not obtain routine imaging or surveillance for asymptomatic hemangioma during pregnancy. D https://web.pathway.md/diseases/recZPcRcjiO2GFdbJ 2/3 6/24/23, 12:41 PM Hepatic hemangioma Pathway 5. Patient education General counseling: As per EASL 2016 guidelines, counsel patients that pregnancy and the use of oral contraceptives are not contraindicated in hepatic hemangioma. B As per ACG 2014 guidelines, counsel patients that pregnancy and the use of oral contraceptives or anabolic steroids are not contraindicated in hepatic hemangioma. B 6. Follow-up and surveillance Indications for referral: As per EASL 2016 guidelines, refer patients to benign liver tumor multidisciplinary team in the presence of Kasabach-Merrit syndrome, growing lesions, or lesions symptomatic by compression. B As per ACG 2014 guidelines, consider referring symptomatic patients with impaired quality of life to an experienced team for operative or nonoperative management. C Serial imaging assessment: do not obtain follow-up imaging in patients with typical cases of hepatic hemangioma due to its benign course. D References 1. Expert Panel on Gastrointestinal Imaging, Victoria Chernyak, Jeanne M Horowitz et al. ACR Appropriateness Criteria Liver Lesion-Initial Characterization. J Am Coll Radiol. 2020 Nov;17 11S S429 S446. Open 2. European Association for the Study of the Liver EASL . EASL Clinical Practice Guidelines on the management of benign liver tumours. J Hepatol. 2016 Aug;65 2 386 98. Open 3. Tram T Tran, Joseph Ahn, Nancy S Reau. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol. 2016 Feb;111 2 176 94; quiz 196. Open 4. Marrero JA, Ahn J, Rajender Reddy K et al. ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol. 2014 Sep;109 9 1328 47. Open 5. Christoph F Dietrich, Christian P llson Nols e, Richard G Barr et al. Guidelines and Good Clinical Practice Recommendations for Contrast-Enhanced Ultrasound CEUS in the Liver-Update 2020 WFUMB in Cooperation with EFSUMB, AFSUMB, AIUM, and FLAUS. Ultrasound Med Biol. 2020 Oct;46 10 2579 2604. Open 6. Monika Sarkar, Carla W Brady, Jaquelyn Fleckenstein et al. Reproductive Health and Liver Disease: Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021 Jan;73 1 318 365. Open https://web.pathway.md/diseases/recZPcRcjiO2GFdbJ 3/3