Torsion of a Fatty Fringe of the Falciform Ligament, a Rare Cause Of

Diagnostic and Interventional Imaging (2013) 94, 637—639

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LETTER / Gastrointestinal imaging

Torsion of a fatty fringe of the falciform ligament, a

rare cause of right hypochondrial pain

a,∗ a

F. Uyttenhove , C. Leroy ,

b a

J.R. Nzamushe Lepan Mabla , O. Ernst

Digestive and Endocrine Imaging Department, Hôpital Claude-Huriez, CHRU de Lille, 59037

Lille cedex, France

Emergency Surgery Department, Hôpital Roger-Salengro, CHRU de Lille, 59037 Lille cedex,

France

Torsion of the colic epiploic fringe or the omentum is a rare but fully acknowledged cause

KEYWORDS of acute abdominal pain, recognised as much from the clinical as from the radiological

Falciform ligament; point of view. The notion of intra-abdominal focal fat infarction (IFFI) has recently been

Acute abdomen; proposed, in order to group these clinical entities together [1].

Appendagitis; We report a case of torsion of the fatty fringe of the falciform ligament, which was

Torsion; conﬁrmed surgically. Computed tomography

Observation

A 46-year-old female patient, a nursing auxiliary, consulted the emergency department

for sudden onset hypochondrial pain which had developed over 3 days. The main features

of her history were an appendectomy and episodes of severe renal colic.

Clinically, there was no fever or jaundice, but there was considerable guarding on

abdominal palpation of the right hypochondrium.

Questioning did not reveal any particular trigger or any analgesic taken that might be

the cause.

Initial laboratory results showed isolated elevation of gamma-GT at 98 IU/L. There was

no inﬂammation or cytolysis.

Ultrasonography, initially requested because of suspected acute cholecystitis, and the

initial abdomino-pelvic CT scan showed an acalculous gall bladder with thin walls. There

was no dilatation of intra- or extra-hepatic bile ducts.

In view of the discordant radiological, clinical and laboratory picture, the patient was

admitted for monitoring. Laboratory results were much the same except for a moderate

increase in CRP to 56 mg/L. The clinical examination was similar.

∗

Corresponding author.

E-mail address: [email protected] (F. Uyttenhove).

638 F. Uyttenhove et al.

Radiological reassessment was undertaken. Another on the surface indicating infarction of the epiploic

ultrasound examination, limited by the patient’s pain and fringe.

again performed without using the superﬁcial probe, con-

tributed nothing. The CT scan performed revealed an oblong

mass, of fatty density with a hyperdense crown and a Discussion

linear hyperdense centre, located at the site of the falci-

form ligament, suggesting torsion of a fatty fringe of this The falciform ligament is a vestige of the ventral mesogas-

ligament. There was also discrete perilesional inﬁltration trium. It stretches sagittally from the superior surface of

(Fig. 1). the liver to the inferior surface of the diaphragm and to

Given the persistent pain, the patient underwent the posterior surface of the anterior abdominal wall. The

laparoscopic exploration which conﬁrmed the diagno- two layers forming it, which continue from the superior

sis (Fig. 2), so that the lesion could be ablated. layer of the coronary ligament, are formed by reﬂection

On histological examination, it was found to be a of the hepatic visceral peritoneum on the diaphragmatic

rounded fragment of adipose tissue with ghosts of peritoneum. In its lower part, it contains the round liga-

adipocytes and ﬁbrous partitions with haemorrhagic suf- ment, the paraumbilical veins and a variable quantity of fat

fusions and the presence of a few inﬂammatory elements [2,3].

The falciform ligament is hardly implicated at all in

current pathology or, at least, little diagnosed. Iatro-

genic internal hernia through the ligament is the condition

principally found. Gangrene, most often related to acute

necrotising pancreatitis, and tumours, benign or otherwise

(lipomas and myxoid sarcomas particularly), have also been

described in relation to it.

Torsion of a fatty fringe of the falciform ligament is a

very rare cause of acute abdominal pain. To our knowledge,

only two cases with radiological and surgical correlation

have been published to date [4,5]. This condition is close

to primary appendagitis, both clinically and radiologically.

The clinical picture and laboratory values are often non-

speciﬁc and may point wrongly towards diagnosis of biliary

colic or cholecystitis. The onset of pain is sudden; it is focal

and elective (the patient can point to the site of his or her

pain) [6]. In laboratory tests, moderate hyperleukocytosis

and increase in CRP may be observed, but results are often

normal.

Figure 1. Axial CT slice passing through the falciform ligament.

Ultrasonography may cause the diagnosis to be sus-

Oblong mass of fatty density, just in front of the ligament (white

pected. Examination of the painful site with a superﬁcial

arrow) with linear hyperdensity in the centre of the mass (the ‘dot’

probe will ﬁnd a hyperechoic, oval, non-compressible mass,

sign). It is associated with inﬁltration of the perilesional fat. Also,

surrounded by a peripheral hypoechoic halo, situated at the

note the hyperdense material located in front of the lesion (paper

clip) placed for the examination at the patient’s point of elective point of maximum pain [7]. However, the sensitivity of this

pain. technique is low, probably because of lack of knowledge of

the condition. Above all, it enables us to eliminate differen-

tial diagnoses. Similarly, elective pain at a point with normal

ultrasonography may possibly point to the diagnosis.

Diagnosis is mainly made as a result of the CT scan, as

in our case, and this therefore appears to be the reference

examination. Injection of a contrast agent is not necessary

for this purpose. Localisation on the skin surface may be of

help, as in our case (Fig. 1). In a painful period, an oval

nodule of fatty density is found, limited peripherally by a

hyperdense ring corresponding to the peritoneum [7,8]. The

nodule occurs under the anterior abdominal wall at the site

of the falciform ligament. At the centre of the inﬂamed

epiploic appendage, there is well-deﬁned, linear or round

hyperdensity known as the ‘dot’ sign. This is caused by

thrombosis of the vessels in the centre of the pathological

fringe [7,9]. Fat inﬁltration is often found at the periphery

of the epiploic appendage involved.

In view of the CT appearance, the other possible differ-

ential diagnosis could be appendagitis of the right colon.

Figure 2. Laparoscopic view of the twisted fatty fringe. The

full arrow shows the falciform ligament. The asterisk indicates the Connection to the falciform ligament can be shown per-

twisted fringe. F: liver. fectly with coronal and sagittal reconstructions (Fig. 3). As

Torsion of a fatty fringe of the falciform ligament 639

Disclosure of interest

The authors declare that they have no conﬂicts of interest

concerning this article.

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