Hemangioma is the most common benign hepatic tumor. Although spontaneous rupture is rare, the mortality rate ranges from 60 to 75%. Only 34 cases have been reported in the literature, with only one report using transcatheter arterial embolization (TAE) alone as treatment. We report a case of spontaneous rupture with \"flowering sign\" of a giant hepatic hemangioma, presenting with acute abdominal pain and shock, while the volume of the hemangioma and blood loss were similar. The patient was successfully managed by transarterial chemoembolization (TACE) alone, which has an operative mortality rate of up to 36.4%.

Malignancy masquerading as liver abscess, and presenting with fever, is mainly described in patients with colorectal cancers with liver metastasis. Primary liver tumors such as hepatocellular carcinoma or intrahepatic cholangiocarcinoma presenting as non-resolving liver abscess is extremely uncommon and carries a dismal prognosis. We present a rare case of non-resolving liver abscess as a presenting manifestation of intrahepatic cholangiocarcinoma.

BACKGROUND: Prior to INASL guidelines, there were no Indian guidelines for management of hepatocellular carcinoma (HCC) in India. The guidelines given by other societies like AASLD, EASL etc are not uniform and not tailored for Indian patients. Hence management practices for HCC in India largely depended on physicians\' individual preferences. This survey aimed to study current practices in management of HCC in India.
METHODS: An online survey was conducted from the platform of a survey portal (www.surveymonkey.com), from December 2012 to April 2013. Invitation to participate in the survey was sent to 1383 doctors of India who were expected to be involved in management of patients of HCC. The survey was of 10 min duration and consisted of questions on how the respondents diagnosed and managed patients of HCC.
RESULTS: Three hundred and seventy-seven doctors answered the survey questions (72% gastroenterologists, 95% working in India). The important points which emerged from the survey are following: (i) The incidence of HCC is increasing in India; (ii) The most common etiologic agent is Hepatitis B responsible for 43% cases; (iii) Only 14% patients present in early stage when curative treatment is possible (BCLC-A); (iv) 90% of these respondents screen for HCC when they first evaluate a cirrhotic patient; (v) While following a patient of cirrhosis most respondents screen for HCC by ultrasound and AFP at every 6 months to 1 year; and (vi) Most (82%) respondents follow some international guideline for staging and treatment of HCC. The respondents also suggested that there is a need for spreading awareness about HCC in public as well as in medical fraternity, and there is a need for a national registry of HCC.
CONCLUSIONS: This is the first survey on management practices on HCC. With the publication of the INASL guidelines on HCC, the diagnosis and treatment of HCC will be more uniform and protocol based. Further such surveys should be carried out at periodic interval to track increasing awareness and better management practices for HCC in India.