A rare etiology of acute abdomen: a falciform ligament necrosis case report

Introduction

The falciform ligament is one of the five ligaments which attach the liver to the anterior abdominal wall and the diaphragm (1). The length of this ligament can vary from a patient to another, as it contains the obliterated umbilical vein. It is an embryonic remnant of the ventral mesentery (2). Furthermore, falciform ligament diseases are quite rare. The causes of inflammation are necrosis are frequently viral or ischemic. In some cases, the etiology can be tumoral or cryptogenic (3). The diagnosis is challenging and may be mistaken for more common causes of abdominal pain, such as gallbladder disease (4). We present a case of a patient with primary falciform ligament necrosis (FLN) that was treated surgically. We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-168/rc).

Case presentation

A 61-year-old patient presented to Etterbeek-Ixelles Hospital with severe abdominal pain mainly located in the right hypochondrium and epigastric region. The patient presented with one episode of vomiting, no fever and no other particular symptom. There was no particular diagnostic challenge. The patient presented a medical history of diabetes and high blood pressure treated with metformin, nebivolol and perindopril. The patient had no relevant past intervention. The clinical exam revealed an epigastric and right hypochondrium pain with no peritoneal signs. The laboratory results revealed an inflammatory syndrome with white blood cell 14,670/cm³ with 81% of neutrophil count (normal range between 4,000 and 10,000 cells per microliter), a glucose of 619 mg/dL (normal range between 70 and 110 mg/dL), a lipase of 7,185 UI/L (normal range between 13 and 60 UI/L), an aspartate amino transferase of 185 UI/L (normal under 40 UI/L), an alanine amino transferase of 116 UI/L (normal under 41 UI/L), phosphatase alcaline of 145 UI/L (normal range between 40 and 130 UI/L), gamma-glutamyltransferase of 737 UI/L (normal range between 8 and 61 UI/L), total bilirubin of 2.3 mg/dL (normal under 1.2 mg/dL), conjugated bilirubin of 1.4 mg/dL (normal under 0.3 mg/dL).

The injected abdominal computed tomography (CT) scan realised concluded in a thickening and edema of the head of the pancreas with infiltration of peri-pancreatic fat compatible with a pancreatitis (CT severity index score: 3). The gallbladder is also thickened and contains gallstones (Figure 1).

Figure 1 Injected abdominal CT scan concluded in a thickening and edema of the head of the pancreas with infiltration of peri-pancreatic fat compatible with a pancreatitis (CT severity index score: 3). The gallbladder was also thickened and contained gallstones. The left image shows acute pancreatitis. The image on the right shows a thickened and infiltrated gallbladder. CT, computed tomography.

The patient is hospitalised in an intensive care unit with the diagnosis of mild acute pancreatitis associated with a probable cholecystitis and uncontrolled diabetes. An analgesic and antibiotic treatment was immediately started.

An abdominal ultrasound was performed the first day after his admission and the diagnosis was acute cholecystitis progressing to gangrene with gaseous distension of the round ligament. Decision was taken to drain the gallbladder under CT scan. Around 25 mL of clean bile was recovered (Figure 2).

Figure 2 Injected abdominal CT scan showing the drainage of the gallbladder. CT, computed tomography.

A new abdominal CT-scan 2 days later shows an increase of the infiltration of the falciform ligament and thrombosis of a segmental portal vein associated with bilateral pleural effusion (Figure 3).

Figure 3 Injected abdominal CT scan shows an increase of the infiltration of the falciform ligament. CT, computed tomography.

X-rays confirms a possible sur-infection with atelectasis of the two pulmonary lower lobes (Figure 4). Unfortunately, the patient begins an acute respiratory distress syndrome (ARDS) and the intensive care unit (ICU) team decides to intubate the patient. Vancomycin antibiotherapy was started to treat the infection.

Figure 4 X-ray confirms pulmonary infection with atelectasis of the two pulmonary lower lobes. Letter “D” signifies the right side of the patient’s thorax. “Au lit” signifies that the X-ray is done while the patient is laying on his back.

After the medical stabilisation of the patient, we decided to perform an abdominal exploratory laparoscopy. Three trocars were placed in the left flank and in the left hypochondria.

At the exploration we found an infected necrosis of the falciform ligament. The ligament was resected and pus taken for culture. The percutaneous drain was removed and replaced by a sub-hepatic drain (Figure 5).

Figure 5 Preoperative picture showing the necrosis of the falciform ligament.

After the surgery, the patient presented a progressive clinical and biological amelioration.

The drain was removed 10 days after the operation. Postoperative follow-up was uneventful, the patient was satisfied with the treatment. A laparoscopic cholecystectomy was scheduled 3 months later.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

FLN is an uncommon condition that presents diagnostic and management challenges. Symptoms are frequently minor and not very specific. As a result, evolution takes longer (weeks rather than days) before an exact diagnosis and subsequent treatment are implemented (5).

Because the disease spreads to nearby organs such as the gallbladder, pancreas, liver, or stomach, disorders of those organs are commonly identified, as in our instance, where pancreatitis was initially suspected. More FLN may infect surrounding organs, making differential diagnosis with a malignant illness challenging (5).

Radiologic tests are, for the same reasons, largely confounding since the disease is widespread, and images of organ infiltration, such as the gallbladder or pancreatic, are more common, and thus more often regarded the primary cause of illness (6).

Finally, if there is gaseous edema and infiltration or a true abscess in the falciform ligament area, laparoscopic exploration is most likely the best approach.

Diagnostic laparoscopy can confirm the diagnosis, evaluate the extent of the disease, and provide sampling while also acting as a therapeutic tool through necrotic tissue excision and effective drainage (4).

Conclusions

Necrosis and inflammation of the falciform ligament represent a rare condition with limited available literature. Patients typically display symptoms resembling those of gallbladder diseases, such as acute cholecystitis or symptomatic pancreatitis (7). When encountering right upper quadrant or epigastric acute pain, or signs of peritonitis without clear evidence of gallbladder inflammation, or stones, surgeons should consider alternative pathologies like FLN. Laparoscopic surgical intervention could be a tool to diagnose this illness and the definitive treatment.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-168/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-168/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-168/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Lim ZS, Tan JYG, Fanning S, et al. Hepatobiliary and Pancreatic: Falciform ligament necrosis. Journal of Gastroenterology and Hepatology 2012;27:1409. [Crossref] [PubMed]
2. Ozkececı ZT, Ozsoy M, Celep B, et al. A rare cause of acute abdomen: an isolated falciform ligament necrosis. Case Rep Emerg Med 2014;2014:570751. [Crossref] [PubMed]
3. Novellas S, Mondot L, Caramella T, et al. Round ligament pathology: a report of two cases. J Radiol 2008;89:510-3. [Crossref] [PubMed]
4. Bhatt A, Robinson E, Cunningham SC. Spontaneous inflammation and necrosis of the falciform and round ligaments: a case report and review of the literature. J Med Case Rep 2020;14:17. [Crossref] [PubMed]
5. Kuribara T, Shigeyoshi I, Ichikawa T, et al. Falciform ligament abscess with disseminated intrahepatic foci: a case report. Surg Case Rep 2022;8:112. [Crossref] [PubMed]
6. Adhikari R, Silwal P, Khadka A, et al. Spontaneous falciform ligament necrosis: A rare case report. Radiol Case Rep 2024;19:4385-91. [Crossref] [PubMed]
7. Awashra A, Nouri A, Hamdan D, et al. Focal necrosis of the falciform ligament as a rare cause of abdominal pain: A case report. SAGE Open Med Case Rep 2024;12: [Crossref] [PubMed]