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 Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 1  |  Issue : 2  |  Page : 53-55

Lipoma of the falciform ligament of the liver as a rare cause of chronic epigastric pain: A case report and review of literature


1 Department of Surgery, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria
2 Department of Radiology, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna, Nigeria

Date of Web Publication20-Apr-2017

Correspondence Address:
Jerry Godfrey Makama
Department of Surgery, Barau Dikko Teaching Hospital, Kaduna State University, Kaduna
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/archms.archms_1_16

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  Abstract 

Pathologic conditions of the falciform ligament of the liver are rare. Only a few cases have been reported. We are reporting a case of chronic epigastric pain due to lipoma of the falciform ligament. Case report and discussion of the relevant literature is presented. A 38-year-old woman presented to the emergency room with a 5-day history of an exacerbated epigastric pain which has been on and off for 3 years. She was wrongly diagnosed to have peptic ulcer disease and has been on anti-ulcer regime for close to 6 months without improvement of symptoms. On physical examination, she was in painful distress, though generally preserved the tenderness in the epigastrium was accompanied by mild local rebound tenderness. Hence, it was difficult to properly delineate the abdominal mass in the epigastrium. Laboratory data done at this occasion and in the past were normal. Plain abdominal X-ray, contrast studies, and esophagogastroduodenoscopy findings were essentially normal. Only abdominal ultrasound revealed a suspected well-defined hypodense area located dorsally to the rectus muscles. Although the computed tomography and magnetic resonance imaging were not done due to logistics and financial constrain the patient presented with haven moved from one clinic to another receiving anti-ulcer regimen. A diagnosis of intra-abdominal mass was made, and the patient subsequently had an exploratory laparotomy. The findings at open operation through an upper midline abdominal incision were a moderate size lipoma of the ligament of the liver which was removed. Postoperative period and recovery was uneventful. Histology revealed well-differentiated adipocytes arranged in the nest with essentially benign features. The patient was discharged home and has remained hailed and hearty for 6 months of surgery. Tension due to lipoma of the falciform ligament of the liver is a rare cause of intractable epigastric pain associated with a diagnostic dilemma.

Keywords: Epigastric pain, falciform ligament, lipoma, liver


How to cite this article:
Makama JG, Kache SA, Yusuf N, Sale D, Baduku ST. Lipoma of the falciform ligament of the liver as a rare cause of chronic epigastric pain: A case report and review of literature. Arch Med Surg 2016;1:53-5

How to cite this URL:
Makama JG, Kache SA, Yusuf N, Sale D, Baduku ST. Lipoma of the falciform ligament of the liver as a rare cause of chronic epigastric pain: A case report and review of literature. Arch Med Surg [serial online] 2016 [cited 2019 Jun 19];1:53-5. Available from: http://www.archms.org/text.asp?2016/1/2/53/204795


  Introduction Top


Extremely, few previous studies [1],[2] have reported on the pathologic conditions of the falciform ligament of the liver such as torsion and/or infarction of the lipomatous appendage of the falciform ligament. In addition, torsion, infarction of intra-abdominal organs containing heavy fat such as omentum and epiploic appendages have also been noted to present with similar features.[3] They have similar etiological factors as well as similar treatment and prognosis like those of torsion of lipomatous appendage of the falciform ligament. Thus, a term known as intra-abdominal focal fat infarction (IFFI)[4] is being proposed and considered to accommodate all of these entities. We report a case of lipoma of falciform ligament of the liver that presented with chronic epigastric pain and mimicked peptic ulcer disease. The diagnosis became obvious only at the surgical exploration of the patient.


  Case Report Top


A 38-year-old woman presented to the emergency room with a 5-day history of an exacerbated epigastric pain which has been on and off for 3 years. Initially, she presented to a peripheral hospital where she was seen and placed on anti-ulcer regime. However, 5 days before presentation to our center, the pain became severe and unbearable despite having being on anti-ulcer regime for close to 6 months. Obviously, it was extremely doubtful if the diagnosis was confirmed before the commencement of anti-ulcer regime. On physical examination, she was in painful distress, though generally preserved the tenderness in the epigastrium was accompanied by mild local rebound tenderness. Hence, it was difficult to properly delineate the abdominal mass in the epigastrium. Plain abdominal film and laboratory data done on this occasion and in the past were normal. Endoscopic and contrast studies/examination of the stomach and duodenum were essentially normal. Abdominal ultrasound examination demonstrated an area of well-defined, hypodense mass which was situated dorsally to the rectus muscles. This hypodense area could not move with the underlying intraperitoneal structures during breathing. No calcification or areas of infarctions were seen. The liver size and parenchymal echogenicity were within normal limits. A diagnosis of an intra-abdominal mass was made and coupled with the fact that the pain was getting worse and unbearable; the patient was planned for exploratory laparotomy. The findings at open operation through an upper midline abdominal incision, was a moderate size lipoma of the ligament of the liver [Figure 1], which was removed [Figure 2], and weighed about 0.9 kg. Postoperative period and recovery was uneventful. Histology revealed well-differentiated adipocytes arranged in nest with essentially benign features. The patient was discharged home and has remained hailed and hearty for 6 months of surgery.
Figure 1: Lipoma of the falciform ligament (preexcision).

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Figure 2: Lipoma of the falciform ligament (postexcision).

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  Discussion Top


The falciform ligament is a double layer of peritoneum that anatomically divides the liver into the right and left lobes. The ligament contains a few structures such as ligamentum teres, the obliterated umbilical veins and a variable amount of extraperitoneal fat. As revealed by previous studies,[1],[2],[3],[4] the fat could undergo an abnormal but progressive growth and enlargement to a size that may cause various conditions which may require surgical intervention. The most common of these conditions as described in the literature has been torsion of the lipomatous appendage of the hepatic falciform ligament.

Many other pathologic conditions of this falciform ligament of the liver have been described. These conditions include internal bowel herniation through it, cystic lesions, neoplastic, and torsion of the lipomatous appendage of the falciform ligament.[3],[4],[5] Other fat-related conditions such as infarction of omentum and torsion of epiploic appendage have been described to have similar etiological factors, presentation and prognosis like that of the lipomas in the hepatic falciform ligament. Hence, an appropriate all-encompassing term that should accommodate all of these entities is being considered. Recently, IFFI has been proposed by Webber et al.[6] Although in our case, there was no clear demonstration of evidence of infarction, this may probably, be due to the fact that our patient had an early operation before infarction set in.

Clinical presentation

One characteristic feature of all of these entities has been a presentation with nonspecific features such as intra-abdominal pain due to fat necrosis, infarction, and torsion. In this patient, the pain may probably be due to tension exerted to the falciform ligament by the lipoma. In all reported cases, no associated symptoms have been reported except one case reported by Maccallum et al.[2] In their case report, though with other medical conditions was a case of torsion of the fatty appendage of falciform ligament presented as acute abdomen in a child which was associated with vomiting, diarrhea, and nausea. Thus, in most cases, they are diagnosed intraoperatively. However, a few have been reported in the past where computed tomography (CT) and magnetic resonance imaging (MRI) were used to confirm the diagnosis.[5] In our patient, the diagnosis was made and established intraoperatively.

Investigations

In our case, preoperative diagnosis was difficult as very basic radiological investigations such as endoscopy and barium meal done were essentially normal. Only abdominal ultrasound revealed a suspected hypodense area located dorsally to the rectus muscles. Although the CT and MRI were not done due to logistics and financial constraints, the patient presented with, having moved from one clinic to another receiving anti-ulcer regimen. Probably, doing CT and MRI could have given an alternative preoperative clue to the diagnosis.

Treatment

Treatment of lipoma of the hepatic falciform ligament has been complete excision of the fat.[1] In our case, the patient had complete excision of the lipomatous mass which was confirmed pathologically, and since then our patient has remained asymptomatic 6 months after the operation.


  Conclusion Top


Tension due to lipoma of the falciform ligament of the liver is a rare cause of intractable epigastric pain associated with a diagnostic dilemma. Hence, a high index of suspicion is key to the management of this condition.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Ozkececi ZT, Ozsoy M, Celep B, Bal A, Polat C. A rare cause of acute abdomen: An isolated falciform ligament necrosis. Case Rep Emerg Med 2014;2014:570751.  Back to cited text no. 1
    
2.
Maccallum C, Eaton S, Chubb D, Franzi S. Torsion of fatty appendage of falciform ligament: Acute abdomen in a child. Case Rep Radiol 2015;2015:293491.  Back to cited text no. 2
    
3.
Nam JG, Choi SH, Kang BS, Kim JY, Kwon WJ. Serial ultrasound and computed tomography findings of torsion of lipomatous appendage of the falciform ligament in a child treated by conservative management. J Korean Soc Radiol 2015;72:368-71.  Back to cited text no. 3
    
4.
Coulier B, Cloots V, Ramboux A. US and CT diagnosis of a twisted lipomatous appendage of the falciform ligament. Eur Radiol 2001;11:213-5.  Back to cited text no. 4
    
5.
Uyttenhove F, Leroy C, Nzamushe Lepan Mabla JR, Ernst O. Torsion of a fatty fringe of the falciform ligament, a rare cause of right hypochondrial pain. Diagn Interv Imaging 2013;94:637-9.  Back to cited text no. 5
    
6.
Webber CE Jr., Glanges E, Crenshaw CA. Falciform ligament. A possible twist? Arch Surg 1977;112:1264.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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