Falciform ligament abscess after omphalitis: report of a case

Falciform ligament abscess management

Falciform ligament abscess (FLA) is a rare occurrence as a consequence of local inflammation. This report presents a case of FLA on a background of recent cholangitis and laparoscopic cholecystectomy complicated by superficial umbilical wound infection. Diagnosis was by clinical examination and CT imaging. Management was by laparoscopic drainage.

Abscess of ligamentum teres hepatis post-endoscopic retrograde cholangiopancreatography: A case report and a literature review

Abscess of the ligamentum teres hepatis has been described in the medical literature as an extremely rare clinical entity, which often presents a diagnostic dilemma. A 68-year-old man was hospitalized for upper abdominal pain and obstructive jaundice. The patient presented with low-grade intermittent fever. Laboratory investigations showed a white blood cell count of 32.38 × 10⁹/L, a C-reactive protein level of 247.86 mg/L, abnormal liver enzyme and bilirubin levels, and elevated serum levels of amylase and lipase. He was first diagnosed with acute biliary pancreatitis. A computational tomography scan and magnetic resonance cholangiopancreatography revealed obstructive choledocholithiasis and cholecystolithiasis. The patient received preoperative antibiotics and symptomatic treatments for 5 days, followed by endoscopic retrograde cholangiopancreatography and a subsequent duodenal papilla incision to extract pigment and cholesterol gallstones. The patient recovered and was discharged on the fifth day after surgery. However, 10 days later, the patient was readmitted for the recurrence of acute calculous cholecystitis. Laboratory tests showed increases in total and direct bilirubin, γ-glutamyltransferase, and alkaline phosphatase, but not inflammatory parameters. After the patient’s nutritional status improved on the 11th day after admission, a laparoscopic cholecystectomy was performed. Intraoperative exploration revealed extensive abdominal adhesions; a thickened edematous gallbladder wall; and an unexpected abscess of the ligamentum teres hepatis. Pus aspiration was performed laparoscopically after laparoscopic cholecystectomy, and to ensure elimination of the abscess, ultrasound-guided pus aspiration was also performed 1 week later. Fortunately, the patient made an uneventful recovery and was discharged with a drain tube on the 16th day after surgery. Doppler ultrasound indicated that the abscess had completely disappeared 2 weeks after discharge. This case highlights an unusual presentation of a ligamentum teres hepatis abscess caused by obstructive cholangitis but that appeared after the choledocholithiasis was resolved. However, the mechanism of abscess formation remained uncertain.

Laparoscopic left hepatectomy for a patient with intrahepatic cholangiocarcinoma metastasis in the falciform ligament: a case report

Background

Intrahepatic cholangiocarcinoma (ICC) is primary cancer of the liver with poor prognosis because of its high potential for recurrence and metastasis. We experienced a rare case of ICC with hematogenous metastasis to the falciform ligament. We aimed to clarify the route of metastasis to the mesentery by increasing the accuracy of preoperative imaging and establish a hepatectomy to control cancer.

Case presentation

An 85-year-old woman was referred to our hospital for a detailed study of progressively increasing liver tumors. She had no subjective symptoms. Her medical history showed hypertension, aneurysm clipping for cerebral hemorrhage, and gallstones. A detailed physical examination and laboratory data evaluation included tumor markers but did not demonstrate any abnormalities. On computed tomography scan, contrast-enhanced ultrasound, and magnetic resonance imaging with gadolinium ethoxybenzyl diethylenetriamine penta-acetic acid, the tumor appeared to be located in liver segment IV, protruding outside the liver. It appeared to contain two distinct components; we suspected ICC in the intrahepatic tumor component. Laparoscopic observation revealed that the extrahepatic lesion was an intra-falciform ligament mass; laparoscopic left hepatectomy was performed. Microscopically, the main tumor in segment IV was 15 mm in diameter and was diagnosed as moderately and poorly differentiated ICC. The tumor of the intra-falciform ligament was not continuous with the main intrahepatic nodule and was also diagnosed as ICC with extensive necrosis. There were no infiltrates in the round ligament of the liver, and several tumor thrombi were found in the small veins of the falciform ligament.

Conclusions

To date, there have been a few reports of metastases of primary liver cancer to the falciform ligament. At the time of preoperative imaging and pathological diagnosis, this case was suggestive of considering that the malignant liver tumor might be suspected of metastasizing to the falciform ligament. Our case improves awareness of this pathology, which can be useful in the future when encountered by hepatic specialists and surgeons.

Spontaneous inflammation and necrosis of the falciform and round ligaments: a case report and review of the literature

Background

Necrosis of the falciform and round ligaments is extremely rare, thus making the diagnosis challenging. It is often misdiagnosed as gallbladder pathology due to the presenting symptoms. Due to the rarity of this pathology, there is limited literature available.

Case presentation

A 53-year-old white man presented to our hospital with signs and symptoms of gallbladder pain but turned out to have the rare entity of necrosis of the falciform and round ligaments. An extensive review of the world literature was performed using PubMed. Manual cross-referencing of reference lists was performed to obtain all available articles. The personal operative log of the senior author was also searched to reveal one additional case. Statistical analysis was descriptive only, given the small number of reported cases. Thirty-nine articles were found, among which forty-three case were identified, and one additional case was extracted from the operative log of the senior author. Unlike previous reports, we found that isolated inflammation and necrosis of the ligaments occurs at nearly the same frequency in both men and women, not predominantly in women as previously reported in smaller series. The mean age at presentation was 59.5 years old, and cases were typically initially diagnosed as gallbladder pathology, most commonly acute cholecystitis. Computed tomography more frequently than ultrasound revealed the falciform and round-ligament pathology.

Conclusions

Isolated falciform and round-ligament inflammation and necrosis is a rare condition that is difficult to diagnose because it can present mimicking a wide variety of intra-abdominal pathologies, particularly gallbladder pathologies. It is often best treated by laparoscopic resection. Unlike prior reports, our review of the literature, which is the largest that we know of to date, shows that males and females are equally affected. Greater awareness of this entity will aid in future diagnosis.

The "sausage" abscess: abscess of the liagamentum teres hepatis

An abscess of the ligamentum teres hepatis is a very rare cause of acute abdomen and can present a diagnostic dilemma. A 40-year-old diabetic male presented with obstructive jaundice and cholangitis. An ill-defined, sausage-shaped, tender parasagittal supraumbilical mass was palpable on the right side. Murphy’s sign was negative. Laboratory investigations revealed polymorphonuclear leukocytosis (total leukocyte count 19,000 mm^–3), elevated alkaline phosphatase (400 IU l^–1), conjugated hyperbilirubinaemia (16 mg dl^–1) and elevated blood glucose (240 mg dl^–1). Ultrasonography and MR cholangiopancreatography revealed cholecystolithiasis, obstructive choledocholithiasis, abscess of the ligamentum teres hepatis and left portal thrombosis. Under ultrasound guidance, pus was aspirated from the abscess and the patient was started on broad-spectrum intravenous antibiotics, insulin and low-molecular-weight heparin. He subsequently underwent endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction. On the tenth day post admission, he underwent laparoscopic cholecystectomy and excision of the ligament. The patient made an uneventful recovery and was discharged on the seventh post-operative day. On follow-up, the patient remained asymptomatic with normal biochemical parameters. This article highlights the importance of suspecting and identifying an abscess of the ligamentum teres hepatis when a patient with acute abdomen presents with a sausage-shaped right parasagittal mass, especially in the setting of cholangitis, cholecystitis or omphalitis.