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BACKGROUND The most common vascular lesions of the liver are hepatic hemangiomas (HH), which are generally asymptomatic and do not require medical intervention. However, when the lesions are large or multiple, they can be a significant clinical problem. This report describes a unique case of an elderly patient with isolated hepatic hemangiomatosis associated with the onset of consumptive coagulopathy and hemolytic anemia, ultimately resulting in liver failure and death. CASE REPORT A 74-year-old man presented with jaundice, progressive weight loss, fatigue, lower-limb edema, and recurrent epistaxis. Laboratory findings revealed normocytic anemia, thrombocytopenia, hyperbilirubinemia, hypoalbuminemia, and elevated liver enzymes. Abdominal ultrasound (US) and computed tomography (CT) demonstrated hepatomegaly with multiple hypoechoic and hypodense focal lesions, initially raising suspicion of metastatic disease. Colonoscopy and upper gastrointestinal endoscopy showed no evidence of malignancy. A core-needle biopsy of the hepatic lesions, complemented by positron emission tomography-computed tomography (PET-CT) and magnetic resonance imaging (MRI), confirmed the benign nature of the lesions, consistent with isolated hepatic hemangiomatosis. The patient was managed symptomatically and discharged home with recommendations for continued outpatient monitoring and urgent consultation in the event of any clinical deterioration. Unfortunately, after 3 months of relative symptoms improvement, he developed gastrointestinal bleeding and acute liver failure, which ultimately resulted in his death. CONCLUSIONS Hepatic vascular lesions are diagnostically challenging; definitive diagnosis requires correlation of clinical, imaging, and histopathological findings, as well as multidisciplinary consultation. The clinical course of hepatic hemangiomatosis ranges from benign to life-threatening, with potential complications such as hepatic failure or coagulopathy.