Teaching Case

68-year-old woman with increasing right upper quadrant pain for 3 days was admitted to our hospital. There was no associated nausea or vomiting. She had severe tenderness in epigastric area. Laboratory studies showed an elevated white blood cell count (14900/ µl), normal lipase, amylase in liver function tests.

Ultrasound showed heterogeneous hyperechogenic area localized right of the midline. Computed tomography demonstrated heterogeneous-hypodense mass of soft tissue in the fissure of falciform ligament including fat attenuation areas and inflammatory changes in the adjacent fat planes (Figure 1 and 2). At laparotomy gallbladder was normal and the falciform ligament was necrotic with adherent omentum. Histopathology of the specimen showed haemorrhagic infarcted and inflamed lipomatous tissue. After two days and uneventful postoperative progress the patient was discharged.

Falciform ligament divides left lobe of liver into lateral and medial segments and extends from inferior surface of diaphragm to supraumbilical part of anterior abdominal wall [1]. It is composed of peritonal layers within obliterated umbilical vein as ligamentum teres and variable amount of adipose tissue [2]. Pathologies like cystic lesions, internal hernia through the ligament, lipomas, haematomas, inflammation and necrosis of ligament have been reported but they are very rare [3, 4]. A septic or thrombotic cause also torsion could lead to gangrene of ligamentum falciforme [5]. Necrosis of falciform ligament is an uncommon cause of acute abdominal pain and can mimic the clinical presentation of cholecystitis, perforated duodenal ulcer and pancreatitis. Ultrasound (US) and computed tomography (CT) is helpful for the assessment of the cause. Non-compressible heterogeneous-hyperechoic mass localized deep to the abdominal wall and right to the midline can be seen on US.¹ CT shows a well-circumscribed mass-like area in the fissure of falciform ligament with fatty attenuation and associated inflammatory changes in the adjacent fat planes [2]. Treatment is generally excision of the ligament because of symptomatic relief and uncertainty of the diagnosis although there are few cases reported treated conservatively. Awareness of radiologists to imaging findings of falciform ligament necrosis will allow inclusion of this rare entity in the differential diagnosis of acute abdomen [1, 2].