Table 2.

Comparison of guideline recommendations on hepatic haemangioma

	ACG (2014)27		SBH (2015)26		EASL (2016)28
Diagnostics	S	An MRI or CT scan should be obtained to confirm a diagnosis of haemangioma.	R	A finding on hepatic nodule(s) consistent with haemangioma on US should be confirmed by contrast-enhanced CT or MRI.	S	In patients with a normal or healthy liver, a hyperechoic lesion is very likely to be a liver haemangioma. With typical radiology (homogeneous hyperechoic, sharp margin, posterior enhancement, and absence of halo sign) in a lesion less than 3 cm, ultrasound is sufficient to establish the diagnosis.
			R	At hepatobiliary centres of excellence where there is absolute certainty of technical quality and professional skill, radiological confirmation (by MRI or CT) of haemangioma may be unnecessary, as long as the patient has no known risk factors.	S	In oncology patients or those with underlying liver disease, contrast-enhanced imaging (CEUS, CT or MRI) is required.
					S	The diagnosis by contrast enhanced imaging is based on a typical vascular profile characterised by peripheral and globular enhancement on arterial phase followed by a central enhancement on delayed phases. MRI provides additional findings such as lesion signal on T1-weighted, T2-weighted sequences, and diffusion-weighted imaging.
	S	Liver biopsy should be avoided if the radiological features of a haemangioma are present.	t	Needle core biopsy carries a risk of life-threatening bleeding and should only be considered in rare cases in which a diagnosis cannot be established conclusively despite the use of multiple imaging modalities and a suspicion of malignancy remains.	t	Percutaneous biopsy can be performed when the diagnosis cannot be achieved with imaging. Provided that a cuff of normal hepatic parenchyma is interposed between the capsule and the margin of haemangioma, needle biopsy is not contraindicated.
Management	W	Pregnancy and the use of CP or anabolic steroids are not contraindicated in patients with a haemangioma.	R	The use of CP or other hormonal therapies is not contraindicated in patients with haemangiomas.	W	Pregnancy and CP are not contraindicated.
	W	Regardless of the size, no intervention is required for asymptomatic hepatic haemangiomas. Symptomatic patients with impaired quality of life can be referred for surgical or non-surgical therapeutic modalities by an experienced team.	R	Patients with symptomatic giant haemangiomas or those presenting with compression of adjacent structures should be referred to a hepatobiliary centre for assessment of surgical or non-surgical treatment options such as enucleation, liver resection, arterial embolisation, and radiofrequency ablation, the efficacy of which remains unconfirmed.	S	Conservative management is appropriate for typical cases.
	t	Surgical intervention can be considered in large lesions (>10 cm), or in case of symptomatic compression or recurrent pain.	R	In the event of rare complications such as rupture (spontaneous or traumatic) or Kasabach-Merritt syndrome, surgical treatment is necessary.	S	In the presence of Kasabach-Merritt syndrome, growing lesions or lesions symptomatic by compression: refer to BLT-MDT*.
Follow-up	t	Follow-up imaging is not required in cases of classical haemangioma.	R	Once the diagnosis has been established conclusively, there is no need for systematic follow-up of asymptomatic patients with small nodules.	S	Due to its benign course, imaging follow-up is not required for typical haemangioma.
			R	Yearly or twice-yearly follow-up ultrasound is recommended for patients with haemangiomas >5 cm in size.
			t	Conservative monitoring during pregnancy is advisable for patients with large tumours.

Green = Moderate level of evidence; Orange = Low level of evidence; Red = Very low level of evidence.

*BLT-MDT should consist of a hepatologist, hepatopancreatobiliary surgeon, diagnostic and interventional radiologist, and a pathologist.

ACG, American College of Gastroenterology; BLT-MDT, benign liver tumour dedicated multidisciplinary team; CEUS, contrast-enhanced ultrasound; CP, contraceptive pills; EASL, European Association for the Study of the Liver; R, recommendation without definition of strength; S, strong recommendation; SBH, Brazilian Society of Hepatology; t, in text advice; US, ultrasound; US, ultrasound; W, weak recommendation/conditional recommendation.