Hepatic hemangioma (HH) is the most probable benign tumor of the liver, and often asymptomatic, can be found accidentally during the imagological examination, has a prevalence of approximately 20%, and is more frequent in women. Clinically, the most common type is a cavernous hemangioma, and most patients have an excellent prognosis because of the benign nature of hemangioma (1). So, most scholars propose that surgery should be restricted to the specific situation. The incidence of HH with rupture is low (1–4%). However, the mortality is rather high. Thus, spontaneous rupture is the most severe complication (2). There is no scientific evidence correlating the size of the hemangioma with the risk of rupture. In this emergency condition, dynamic contrast-enhanced computed tomography (CT) scanning, especially triple-phase CT with delayed imaging, is preferred. Herein, we presented two patients in our hospital, whose HHs were spontaneously ruptured, and whose hemangiomas are less than 10 cm in diameter. Following an accurate diagnosis of enhanced CT and emergency surgery, patients recovered well and were discharged from the hospital.

Hepatic hemangioma is the most probable benign neoplasm and is often found in women. The majority of HH is a cavernous hemangioma, with little chance of malignant transformation (3). After improving people’s health consciousness, more and more patients with hemangioma have been found. HHs grow slowly, and the course often lasts for many years. In most cases, the diameter of HH (<4 cm) is usually asymptomatic and easy to ignore, being discovered only as an incidental imaging finding. At >4-cm diameter, HHs are considered gigantic in size and might result in symptoms, such as abdominal discomfort, rupture, internal hemorrhage, coagulation disorder, etc. (4).

Reports of HH with spontaneous hemorrhage are less, causing a misunderstanding and ignorance of its serious complications (5). The incidence of abdominal bleeding caused by ruptured HH is low (1–4%), the mortality ranges from 60 to 70% (2), and the surgery mortality rate from this complication is 36.4% (6). There has been no scientific evidence correlating the size of the hemangioma with the risk of rupture. The first spontaneous rupture case of HH was reported by Van Haefen in 1898 (7). Yamamoto et al. documented 28 cases of ruptured tumors, with sizes ranging from 3 to 25 cm (8). To more comprehensively understand this disease, we searched PubMed and found 13 cases reported in recent 20 years (Table 1). These previous reports, combined with our case report, will significantly contribute to the diagnosis and treatment of spontaneous rupture of HH.

Clinical manifestation of spontaneous rupture of HH consists of sudden abdominal pain, anemia that is secondary to a hemoperitoneum, and disseminated intravascular coagulopathy (DIC). Spontaneous rupture of HH is considered a life-threatening condition (9), as its clinical signs are not usually specific. Dynamic contrast-enhanced CT scanning, especially triple-phase CT with delayed imaging, is preferred. Conservative treatment may result in hypovolemic shock, and emergent hepatic resection should be applied, although high operative mortality (10). Thus, emergency surgery is needed for patients with clinical symptoms, and high-risk complications should be more actively treated.

At present, due to a poor understanding of the natural history of asymptomatic hemangiomas (11), patients might have died unexpectedly when hemangioma ruptured into the abdominal cavity without surgical treatment. An accurate diagnosis of a hemangioma as the cause of a hemoperitoneum would result in correct clinical decision-making and treatment. Thus, enhanced CT and emergency surgery are necessary for ruptured or bleeding HHs. We hope that our cases will attract more attention to this complication in clinical work. It requires us to reconsider indications for surgery.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Written informed consent was obtained from the patient for the publication of this case report. Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article.

BP and S-CL contributed to the planning and organization, collected clinical data, supervised the findings of this work, analyzed the results, and prepared the manuscript. QH aided in the data collection and supervision. All authors contributed to the article and approved the submitted version.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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