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Variance with Guidelines in Hepatic Hemangiomas

April 1, 2026 7:00 am

TL Mosher et al. J Pediatr Gastroenterol Nutr. 2026;82:765–769. Guidance adherence in the evaluation and management of hepatic hemangiomas in infants and children

Background: Hepatic hemangiomas are one of the visceral hemangiomas that can be seen and are categorized as infantile or congenital.^1, 2 Infantile hepatic hemangiomas (IHH) develop in the first weeks-to-months of life, reach peak size typically by 3 months and often spontaneously involute without medical management within 1–2 years.³ Congenital hepatic hemangiomas (CHH) are present at birth and may rapidly involute, partially involute, or remain static for life.

Guidelines for screening with imaging and laboratory evaluation have been previously published and highlight differences between IHH and CHH.² (Reference: Iacobas I, Phung TL, Adams DM, et al. Guidance document for hepatic hemangioma (infantile and congenital) evaluation and monitoring. J Pediatr. 2018; 203: 294-300 e2).” Screening with blood counts, fibrinogen, liver function tests, alpha-fetoprotein (AFP), thyroid function tests (TFTs), should be performed at diagnosis for both types of hemangiomas with frequency of repeat testing depending on whether IHH or CHH is diagnosed.² Echocardiogram at diagnosis should be considered in both if patients have symptoms of cardiac failure. Serial monitoring with liver ultrasounds for at least 1 year or until stable size and vascularity twice in a row is recommended for CHH whereas continued monitoring with ultrasound until complete involution is recommended for IHH.²“

Methods: This study was a retrospective chart review with 64 patients

Key findings:

29 (46%) had CHH and 34 (54%) had IHH
In those 47 patients who were monitored clinically, 62% (n = 29/47) had ALT/AST collected whereas only 51% (n = 24/47) TSH/FT4, 55% (n = 26/47) AFP, and only 26% (n = 12/47) had an INR drawn. Only about one-third (28%, n = 13/47) had a screening echocardiogram performed during evaluation
When comparing across hemangioma type, patients with CHH were significantly less likely than those with IHH to have TSH/FT4 (26% vs. 75%, p < 0.001) or AFP (39% vs. 71%, p = 0.002) drawn
Sixteen patients (25%), 6 with CHH and 10 with IHH, required active management.
- Among CHH patients, one (17%) received propranolol prior to transfer to our institution, two (33%) underwent embolization, one (17%) surgical resection, and two (33%) required multiple modalities (i.e., surgery plus embolization). Two patients with CHH receiving multiple treatment modalities developed multi-system organ failure and died.
- Among IHH patients, most patients (90%) received propranolol and one (10%) underwent surgical resection.

Discussion Points:

“Current guidance recommends screening for the complications of hepatic hemangiomas, particularly in patients with diffuse or multifocal hemangiomas, as they are at increased risk for heart failure and hypothyroidism.”

“Current guidance recommends monitoring of hepatic hemangiomas until complete involution of the hemangioma is documented.^2, 10 These recommendations are in place given the devastating sequelae that can develop in patients with proliferation of hemangiomas that may be missed when not evaluated with serial abdominal imaging.”

My take: This study shows that about 25% of these patients require medical intervention and is a good reminder of the recommended evaluations.

Related blog posts:

Natural History and Management of Congenital Hepatic Hemangiomas (this 2025 post has easy algorithm for evaluation)
Incidental Liver Lesions -What to Do
Liver Masses -Helpful Reference
Liver Updates: Statin Protection from HCC, PSVD -new name, novel finding and Hypothyroidism with Hepatic Hemangiomas

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