How to manage a patient with liver hemangioma and iron deficiency anemia?

Management of Liver Hemangioma with Iron Deficiency Anemia

Patients with liver hemangioma and iron deficiency anemia should receive oral iron supplementation with ferrous sulfate 200 mg three times daily as first-line treatment, while simultaneously investigating the underlying cause of blood loss, which may or may not be related to the hemangioma. 1

Evaluation of Iron Deficiency Anemia

• All patients with iron deficiency anemia require investigation to determine the underlying cause, as the hemangioma may not be the source of blood loss 1

• Initial workup should include:

  • Complete blood count with MCV (typically <76 fl in iron deficiency) 1
  • Serum ferritin (typically <15 mg/dl in iron deficiency) 1
  • Upper GI endoscopy with small bowel biopsy and colonoscopy/barium enema to rule out common sources of GI blood loss 1

• Further evaluation is necessary if the anemia is transfusion-dependent or there is visible blood loss:

  • Enteroscopy may be helpful to detect small bowel angiodysplasia 1
  • Deep enteroscopy with distal attachment improves detection of small bowel angioectasias 1
  • Consider mesenteric angiography for transfusion-dependent anemia to demonstrate vascular malformations 1

Relationship Between Liver Hemangioma and Iron Deficiency Anemia

• Liver hemangiomas are the most common benign liver tumors and are usually incidental findings 2
• The connection between liver hemangiomas and iron deficiency anemia is rare but has been documented 3, 4
• Potential mechanisms include:
  • Direct blood loss into the hemangioma (rare)
  • Microangiopathic hemolytic anemia (rare complication) 5
  • Possible hepcidin-mediated anemia (requires further evaluation) 4

Treatment of Iron Deficiency Anemia

• Oral iron supplementation is the first-line treatment 1:

  • Ferrous sulfate 200 mg three times daily is most commonly recommended 1
  • Ferrous gluconate and ferrous fumarate are equally effective alternatives 1
  • Liquid preparations may be better tolerated when tablets cause side effects 1
  • Add ascorbic acid to enhance iron absorption if response is poor 1

• Iron therapy should be continued for three months after correction of anemia to replenish iron stores 1

• For patients not responding to oral iron:

  • Parenteral iron should be used if the patient does not tolerate oral iron after trying at least two different preparations 1
  • Intravenous iron formulations that require only 1-2 infusions are preferred 1
  • Note that parenteral iron can cause pain (when given intramuscularly) and rarely anaphylactic reactions 1

Management of the Liver Hemangioma

• Most liver hemangiomas can be observed without intervention, even large ones 2
• Surgical resection should be considered if:
  • The hemangioma is >5 cm AND causing progressive abdominal pain 2
  • There is evidence that the hemangioma is the source of blood loss causing the anemia 3
  • In cases where the hemangioma is confirmed as the cause of refractory anemia despite iron supplementation 3, 4

Follow-up

• Monitor hemoglobin concentration and red cell indices at regular intervals:
  • Every three months for the first year
  • Then annually after the first year 1
• Additional oral iron should be given if hemoglobin or MCV falls below normal 1
• Further investigation is only necessary if the hemoglobin and MCV cannot be maintained with iron supplementation 1

Common Pitfalls and Caveats

• Do not assume the liver hemangioma is the cause of iron deficiency anemia without thorough investigation of other common causes 1
• Failure of hemoglobin to rise by 2 g/dl after 3-4 weeks of oral iron therapy suggests:
  • Poor compliance
  • Misdiagnosis
  • Continued blood loss
  • Malabsorption 1
• Routine liver function tests are of no diagnostic value for iron deficiency anemia unless there is specific suspicion of systemic disease 1
• Fecal occult blood testing is not recommended as it is insensitive and non-specific 1