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A previously healthy 58-year-old woman presented to the emergency department with epigastric pain and dizziness. She reported recurrent episodes of epistaxis, and her elder sister also had a similar condition. A physical examination was performed with physical signs illustrated in figure 1 A, B. Blood tests revealed a haemoglobin level of 66 g/L and an elevated alkaline phosphate (ALP) level of 174 U/L. Other liver enzymes were within normal range. To investigate the cause of anaemia, an oesophagogastroduodenoscopy was performed and was non-revealing. Colonoscopy was conducted with an endoscopic view of the ascending colon depicted in figure 1C. Contrast-enhanced CT of the abdomen was done in view of epigastric pain and a raised ALP level. CT revealed a nodular liver with diffuse mottled enhancement in the arterial phase, as well as an iso-enhancing mass (6.0×4.5 cm) with a central scar in segment IV of the liver (figure 1D). Both the liver and spleen were normal in size. Arteriovenous and arterioportal shunts were also noted. Extensive workup for chronic liver disease was negative.