Intraperitoneal focal fat infarction: the great mimicker in the acute setting

Isolated Inflammatory Necrosis of the Falciform Ligament: A Case Report with Review of Literature

Inflammatory necrosis of the falciform ligament is an extremely rare cause of acute right upper quadrant pain. Due to overlapping symptoms with pathologies affecting the gall bladder and liver, this poses a diagnostic challenge with limited existing literature. Here, we report a case of a 62-year-old female patient presenting in the accident and emergency department with right upper quadrant pain. The patient underwent ultrasonography and revealed thickened and echogenic falciform ligament. Further, a computed tomography revealed swollen falciform ligament with associated fat stranding. The patient was kept under conservative management and improved over 2 weeks.

Falciform Ligament Infarction: A Case Report and Review of the Literature

The falciform ligament is a double peritoneal fold that separates the left and right hepatic lobes anatomically. Fatty-falciform ligament appendage torsion (F-FLAT) is defined as torsion of the extraperitoneal fat within the falciform ligament causing fat infarction, which is an uncommon surgical presentation, scarcely documented within the current literature. The objective of presenting this case report and reviewing the literature on F-FLAT is to discuss the clinical presentation, possible associated factors and management strategies in regard to this rare pathology. A 72-year-old female patient presented to the emergency department with a seven-day history of epigastric pain, reduced appetite and nausea. On admission, the patient was stable and apyrexial with abdominal examination highlighting she was tender in her right upper quadrant and epigastric region. Due to the patient's unremitting abdominal pain despite appropriate analgesia, CT of the abdomen and pelvis (CTAP) with intravenous contrast was done and a diagnosis of F-FLAT was made. The patient was treated with antibiotics and analgesia, had a negative abdominal ultrasound (US) result and due to her symptoms settling by the second day of admission, she was discharged the same afternoon. A literature review into falciform ligament infarction was conducted by two independent reviewers across four different databases: PubMed, Medline, Embase and the Cochrane Library. Search terms included "falciform ligament" OR "falciform" AND "infarction" (likewise with Medical Subject Headings, or MeSH, terms in the Cochrane Library). Eligibility criteria and our subsequent inclusion criteria were based on studies specifically discussing falciform ligament infarction and published in English. Study types were by majority case reports, but also included one literature review and a book source as well as two pictorial radiological reviews. All 13 patients presented with abdominal pain, but only 53% presented with raised infective/inflammatory markers. The majority of patients had abdominal US as a first-line investigation with 9 of 13 patients also having a CTAP with contrast, which classically showed fat stranding in the falciform ligament. Two patients had no evidence of any radiological investigation. Initially all cases were managed conservatively with non-steroidal anti-inflammatory drugs and analgesia, but in 62% of the cases (8/13), surgical intervention was needed due to unresolving abdominal pain. All eight of the excised falciform ligaments showed evidence of infarction and necrosis histologically. In conclusion, F-FLAT is a relatively rare condition making it difficult to build higher level evidence studies. The current literature has revealed some evidence of incomplete and inconsistent data, for example, in the biochemical results and management techniques presented, yet contrast-enhanced CT seems moderately sensitive for detection in the reviewed literature. Though F-FLAT is rare and unfamiliar, it is vital we exclude common acute surgical pathologies that F-FLAT mimics and monitor for unsettling symptoms that could change the management trajectory.

Primary omental torsion in children: single-center experience of 17 cases

OBJECTIVE

Primary omental torsion (POT) is a rare condition in children often misdiagnosed because of a lack of clinical manifestations. Here we present insights gained from the treatment of pediatric POT cases at a single center over 8 years and summarize some influencing factors found in diagnosis and treatment, in order to reduce the misdiagnosis of POT in children in the future.

METHODS

Demographic and clinical data of 17 children with POT treated in Shanghai Children's Hospital, Shanghai Jiaotong University from June 2012 to December 2020 were reviewed.

RESULTS

The mean age of the 17 pediatric patients was 7.65 ± 2.12 years (range: 4-12 years), sixteen were male. The average time from the pain onset to operation was 73.82 ± 47.21 h (range: 21-144 h). In 5 cases, the ultrasound scan revealed a low-intensity inflammatory mass in the abdominal cavity. Only 1 of the 17 patients had normal body mass index, while others were overweight or obese. The mean computed tomography (CT) value of the mass in the lower right abdomen was - 58.74 ± 10.32 HU (range: - 70 to - 46 HU), which is close to that of its own abdominal wall fat [- 46.29 ± 9.45 HU (range: - 62 to - 32 HU)]. The location of the mass was located in front of the right colon in ten cases, except for two cases near the ligamentum teres. Five patients had whirl sign on CT images and 8 patients had pelvic fluid. Five cases were diagnosed as acute appendicitis and 12 were diagnosed as POT, the preoperative diagnosis was correct in 70.59% of cases. All 17 patients were treated with laparoscopic omentectomy. The average duration of hospitalization was 5.53 ± 1.12 days (range: 4-8 days). All cases were followed up. 1 case relapsed 8 months post operation, while the remaining cases had no complications.

CONCLUSION

POT is rare in children with acute abdominal pain, which is more common in obese boys. The fatty mass in front of colon and between rectus abdominis sheath in CT image is specific, which is helpful for diagnosis of POT. Laparoscopy is an effective method for the treatment of POT in children.