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

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Torsion of a Fatty Fringe of the Falciform Ligament, a Rare Cause Of Diagnostic and Interventional Imaging (2013) 94, 637—639 View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector 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 a Digestive and Endocrine Imaging Department, Hôpital Claude-Huriez, CHRU de Lille, 59037 Lille cedex, France b 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). 2211-5684/$ — see front matter © 2013 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.diii.2013.01.016 638 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. References [1] Van Breda Vriesman AC, Lohle PN, Coerkamp EG, Puylaert JB. Infarction of omentum and epiploic appendage: diagnosis, epi- demiology and natural history. Eur Radiol 1999;9(9):1886—92. [2] Bills D, Moore S. The falciform ligament and the ligamentum teres: friend or foe. ANZ J Surg 2009;79(10):678—80. [3] Li XP, Xu DC, Tan HY, Li CL. Anatomical study on the morphol- ogy and blood supply of the falciform ligament and its clinical significance. Surg Radiol Anat 2004;26(2):106—9. [4] Coulier B, Cloots V, Ramboux A. US and CT diagnosis of a twisted lipomatous appendage of the falciform ligament. Eur Radiol Figure 3. Sagittal MPR. The fringe, the site of torsion (arrow 2001;11(2):213—5. head), is in contact with the falciform ligament, just below the [5] Lloyd T. Primary torsion of the falciform ligament: com- umbilical vein (full arrow). puted tomography and ultrasound findings. Australas Radiol 2006;50(3):252—4. management of these two conditions is similar, the distinc- [6] Rao PM, Wittenberg J, Lawrason JN. Primary epiploic tion is of minor importance. appendagitis: evolutionary changes in CT appearance. Radiology Treatment is basically conservative, since a spontaneous 1997;204(3):713—7. evolution is to be preferred. However, in our case, surgical [7] Almeida AT, Melao L, Viamonte B, Cunha R, Pereira JM. Epiploic appendagitis: an entity frequently unknown to clinicians– exploration removed the diagnostic doubt. diagnostic imaging, pitfalls, and look-alikes. AJR Am J Roentgenol 2009;193(5):1243—51. Conclusion [8] Taourel P, Baud C, Lesnik A, Le Guen V, Pujol J, Bruel JM. Le per- itoine acteur de la pathologie abdominale. J Radiol 2004;85(4 Pt 2):574—90. Although very rare, radiologists should know of this IFFI of [9] Singh AK, Gervais DA, Hahn PF, Rhea J, Mueller PR. CT the falciform ligament, in order to avoid diagnostic error appearance of acute appendagitis. AJR Am J Roentgenol and optimise patient management. 2004;183(5):1303—7..
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