Falciform Ligament Abscess Research Articles

621 Delayed Presentation of Retained Gallstones Post Laparoscopic Cholecystectomy - Complicated by Falciform Ligament Abscess Formation

Abstract Case 30-year-old female presented with six days of intermittent epigastric pain, increasing severity, with associated nausea and vomiting. Past history included depression, smoking and a laparoscopic cholecystectomy and intraoperative cholangiogram (IOC) performed interstate 8mths prior for acute cholecystitis. The operation report described a normal IOC, significantly inflamed gallbladder, requiring needle decompression and retrieval of two 15-20mm gallstones from Morison’s pouch. Investigations showed elevated white cell count(13x10^9/L) and C-reactive protein(56mg/L), with mildly cholestatic liver function tests. Computed Tomography revealed two 1.5cm lesions abutting the inferior margin of the liver; one with shadowing on Ultrasound suspicious for a gallstone, with surrounding inflammatory mass and fat stranding. A laparoscopic exploration and removal of retained gallstone was performed. Intraoperative findings included adhesions between the gastric body and falciform ligament; with chronic abscess cavity containing pus and a 1.5cm gallstone within the falciform ligament. She recovered well and discharged with antibiotics the next day. Discussion Gallstone spillage occurs in 6-40% of laparoscopic cholecystectomies, potentially causing complications (abscess, fistula, or haemorrhage) in 8.5% if retained. Abscess formation (as above) is often recurrent if the gallstone is not removed, thus a laparoscopic technique is preferable. Attempted removal during surgery and documentation of spilled gallstones in the operation report is imperative to alert medical teams to the possibility of a complication if the patient were to represent. A high level of suspicion aids in the early recognition and intervention; particularly given the time post initial operation and limitations of standard imaging in detection of retained gallstones.

Necrosis of Falciform Ligament Complicating a Cholecystitis with a Pylephlebitis and Abscess of the Abdominal Wall

Gangrene of the hepatic ligaments (falciform and/or round) is an exceptional and poorly understood condition and may present a diagnostic dilemma. We report a case of necrotic falciform ligament abscess with pylephlebitis secondary to pyocholecyst. The clinical picture was impressive and noisy. The diagnosis was evoked on the CT scan, with the discovery of a circumscribed lesion of fatty density, pre-hepatic, in the fissure of the round ligament, at the junction of segments III and IV of the liver. The interest of surgical exploration is mainly diagnostic insofar as the evolution is always favourable, independently of the modalities of excision of the necrotic zones. In this article, we discuss the diagnostic and therapeutic features of this entit.

Abscess of the Falciform Ligament Mimicking an Extrahepatic Bile Duct Tumour: a Case Report and Review of the Literature

The abscess of the falciform ligament (FL) is a rare condition in adult patients and can occur in the context of acute cholangitis, acute pancreatitis, torsion of the FL itself or spontaneously. Abdominal imaging often helps making a correct diagnosis. We reported a case of FL abscess and the review of the literature. A 78-year-old male was admitted to hospital with acute pancreatitis secondary to hypercholesterolaemia; the computed tomography (CT) scan of the abdomen demonstrated the presence of appendagitis of the FL. After receiving medical treatment, the patient was discharged with planned clinical and radiological follow-up. The magnetic resonance cholangio-pancreatography (MRCP) and abdominal CT scan showed the progression of the inflammatory changes to the porta hepatis, which raised the suspicion of an extrahepatic bile duct tumour; given the diagnostic uncertainty, the patient underwent diagnostic laparoscopy that allowed for the correct diagnosis and treatment. The abscess of the FL is uncommon in adults and radiological findings can be misinterpreted as other clinical conditions; a high index of suspicion is required to formulate a correct diagnosis with the aid of diagnostic laparoscopy.

Falciform ligament abscess with disseminated intrahepatic foci: a case report

BackgroundFalciform ligament abscess (FLA) is a rare disease, and its diagnosis can be challenging without typical image findings of an abscess. We report a patient with FLA that presented as a mass, with an indistinct border between it and the liver, in addition to disseminated foci within the liver. This made it difficult to determine whether it was FLA or a malignancy.Case presentationA 69-year-old man presented with epigastric pain. Contrast-enhanced computed tomography revealed a 25-mm mass below the middle of the diaphragm. Based on an initial diagnosis of infection of the falciform ligament, we administered conservative antibiotic treatment and there was initial improvement in the patient’s clinical condition and laboratory data. However, he continued to experience mild epigastric pain. A month later, imaging studies revealed enlargement of the falciform ligament mass and the emergence of a new nodule in the liver, whereas laboratory findings showed re-elevated C-reactive protein levels. Since conservative treatment had failed, we decided to perform surgery. Considering the imaging study findings, malignant disease could not be ruled out. Based on the operative findings, we performed combined resection of the falciform ligament, left liver, and gallbladder. Histopathological examination of the resected specimens revealed extensive neutrophil infiltration and the presence of giant cells and foam cells within the lesions. These findings were indicative of abscess. Pseudomonas aeruginosa was cultured from the pus in the falciform ligament mass and bile in the gallbladder. Although multiple abscesses postoperatively developed in the residual portion of the liver, they could be treated through antibiotic therapy.ConclusionsFLA can spread to both adjacent and distant organs via its rich vascular and lymphatic networks. When FLA displays atypical image findings and/or an atypical clinical course, it can be difficult to distinguish it from malignant disease. In such cases, surgical treatment, with intraoperative pathological diagnosis, should be attempted.

Falciform ligament abscess after resection of a patent urachus

Abstract Abscess formation of the falciform or round ligament of the liver is rare. A 15-year-old boy was diagnosed with Hirschsprung's disease after birth and underwent surgery for transverse colostomy at the site of the left upper abdomen in the neonatal period. A radical operation for Hirschsprung's disease was performed with a widely extended incision of the colostomy at 3 months of age. When he was 14 years old, he presented with lower abdominal pain due to a patent urachus. Six months after excision of the patent urachus, he returned to our outpatient clinic, showing pain and a palpable mass at the middle upper abdomen. We report herein a case of abscess formation of the round ligament of the liver after surgical resection of a patent urachus. We also review previous literature and discuss the possible pathogenesis and mechanisms of this phenomenon.

Falciform ligament abscess: a report of two cases

Falciform ligament abscess (FLA) is very rare. The rarity and obscure location often cause delay in diagnosis and inadequate treatment. We are here describing two cases of FLA in infants; presentation, hospital course, and outcome of both the children were different. Early consideration of falciform ligament pathology is crucial for timely diagnosis and proper treatment.

Minimally Invasive Treatment of Falciform Ligament Abscess in a 25-Day-Old Neonate: A Case Report

Minimally Invasive Treatment of Falciform Ligament Abscess in a 25-Day-Old Neonate: A Case Report

保存的治療に抵抗性を示した成人肝鎌状間膜膿瘍の1例

保存的治療に抵抗性を示した成人肝鎌状間膜膿瘍の1例

Falciform ligament abscess secondary to neonatal omphalitis, a potential complication of home delivery.

Falciform ligament abscess secondary to neonatal omphalitis, a potential complication of home delivery.

Falciform ligament abscess from left sided portal pyaemia following malignant obstructive cholangitis

Abscess formation of the falciform ligament is incredibly rare and perplexing when encountered for the first time. It is reported to occur in the setting of cholecystitis and cholangitis, but the pathophysiology is poorly understood.In this case report, we present a 73-year-old man with falciform ligament abscess following cholangitis from an obstructive ampullary carcinoma. The patient was referred to the Royal Adelaide Hospital from a country hospital, with progressive jaundice, anorexia and nausea. Prior to transfer, he deteriorated with cholangitis, dehydration and renal failure. On arrival, his abdomen was exquisitely tender along the course of the falciform ligament. His blood tests revealed an elevated white cell count of 14.9 x 103/μl, bilirubin of 291μmol/l and creatinine of 347 μmol/l. His CA 19-9 was markedly elevated at 35,000 kU/l. A non-contrast computed tomography (CT) demonstrated gross biliary dilatation and a collection tracking along the path of the falciform ligament to the umbilicus.The patient was commenced on intravenous antibiotics and underwent an urgent endoscopic retrograde cholangiopancreatogram (ERCP) with sphincterotomy and biliary stent drainage. Cholangiogram revealed a grossly dilated biliary tree, with abrupt transition at the ampulla, which on biopsy confirmed an obstructing ampullary carcinoma. Following ERCP, his jaundice and abdominal tenderness resolved. He was optimized over 4 weeks for an elective pancreaticoduodenectomy.At operation, we found abscess transformation of the falciform ligament. Copious amounts of pus and necrotic material was drained. Part of the round ligament was resected along the undersurface of the liver. Histology showed that there was prominent histiocytic inflammation with granular acellular eosinophilic components. The patient recovered slowly but uneventfully.A contrast CT scan undertaken 2 weeks post-operatively (approximately 7 weeks after the initial CT) revealed left portal venous thrombosis, which was likely to be a delayed discovery and was managed conservatively.We present this patient’s operative images and radiographic findings, which may explain the pathophysiology behind this rare complication. We hypothesize that cholangitis, with secondary portal pyaemia and tracking via the paraumbilical veins, can cause infectious seeding of the falciform ligament, with consequent abscess formation.

Hepatobiliary and Pancreatic: Falciform ligament necrosis

The falciform (sickle-shaped) ligament is one of five ligaments that connect the liver to the under-surface of the diaphragm and to the anterior abdominal wall. It passes in an antero-posterior plane and is the embryonic remnant of the ligamentum teres and the para-umbilical veins wrapped within two layers of peritoneum. It may contain a variable amount of extra-peritoneal fat and represents a potential space. In infants, falciform ligament inflammation or necrosis can occur as a complication of omphalitis. In adults, a falciform ligament abscess is a rare complication of instrumentation during laparoscopic surgery. The ligament can also become canalized in patients with portal hypertension creating engorged veins which radiate from the umbilicus (caput medusae). Another rare complication is inflammation of the falciform ligament associated with acute cholecystitis. In the patient illustrated below, abdominal pain appeared to be caused by necrosis of the falciform ligament, perhaps related to mild cholecystitis or ischemia. A male, aged 88, was transferred to our hospital with a 2-week history of increasing pain in the right upper quadrant of his abdomen. On arrival, he was noted to be febrile (37.8°C) and hypotensive and required admission to an Intensive Care Unit. Blood tests revealed an elevated white cell count (24x10/l) and C-reactive protein (179 mg/l) and minor changes in liver function tests. An abdominal computed tomography (CT) scan showed dilated intrahepatic ducts and a thickened gallbladder wall with multiple stones (Figure 1). Endoscopic sphincterotomy was performed at the time of endoscopic retrograde cholangiopancreatography but only two very small stones were removed from the bile duct. Although his blood tests appeared to improve, he continued to have pain in the right upper quadrant with clinical features of localized peritonitis. Magnetic resonance cholangiopancreatography (MRCP) confirmed effective decompression of the biliary system but a fluid tract with subacute hemorrhage was seen extending from the portahepatis to the anterior abdomen (Figure 2). Review of the initial CT scan identified a fluid collection with no interval change in size compared to MRCP (Figure 1, arrow). At laparotomy, the falciform ligament was found to be necrotic with possible involvement of the posterior rectus sheath. The falciform ligament was excised and a cholecystectomy was performed although the gallbladder did not appear to be inflamed. Histology of the falciform ligament showed large areas of hemorrhagic necrosis with no evidence of abscess formation. Unfortunately, he died 7 days after surgery because of pulmonary complications.

Falciform Ligament Abscess after Omphalitis: Report of a Case

A falciform ligament abscess is a rare type of intra-abdominal abscess. A 2-yr-old male, who had omphalitis two months previously, presented with a fever and right upper quadrant abdominal pain. The ultrasound and CT scan showed an abdominal wall abscess located anterior to the liver, which was refractory to conservative management with percutaneous draninage and antibiotics. On the third recurrence, surgical exploration was performed and revealed an abscess arising from the falciform ligament; the falciform ligament was excised. A follow up ultrasound confirmed complete resolution of the abscess with no further recurrence.

Falciform ligament abscess with portal pyemia in a newborn

An 18-day-old female neonate presented with abdominal distention and bilious vomiting for 5 days. Abdominal examination showed hepatomegaly and a mass in the right hypochondrium. Ultrasound showed an extrahepatic cyst with internal echoes and dilated intrahepatic radicals. A contrast computer tomography showed a large cyst arising from the falciform ligament, extending into the liver parenchyma and a dilated portal venous system. Diagnosis of falciform ligament abscess with portal pyemia was made. Excision of the falciform ligament was done. After a follow up of 1 year, the child remains asymptomatic. To our knowledge, a falciform ligament abscess causing intrahepatic portal pyemia in a newborn has not been previously been described.

Gastrointestinal complications following orthotopic lung transplantation

GASTROINTESTINAL COMPLICATIONS FOLLOWING ORTHOTOPIC LUNG TRANSPLANTATION Gary R. Lichtenstein, Erica I. Lubetkin, Harold L Palevsky, Robert Kotloff, M.D., Jon Morris, M.D., Jesse A. Berlin, Joseph E. Bavaria Angela B. Wurster, Larry R. Kaiser, M.D. Departments of Medicine, Surgery, and Center for Clinical Epidemiology and Binstatistics, Hospital of the University of Pennsylvania (HUP), Philadelphia, PA. Background/Aims: Within the last decade lung transplantation has been performed with increasing frequency and successful outcomes. Systematic analsysis of GI complications in a large cohort of lung traiasplant recipients has not been performed to date. The present Study describes and categorizes such GI complications. Methods: Between November 1991 and January 1994, 45 patients underwent 47 single or bilateral o'rthotopic lung transplant procedures at the HUP. Immunosuppression consisted of cyclosporine, azathioprine, and corticosteroids. A retrospective chart analysis was performed, ..Results: Twenty-three patients (51%) had 69 gastrointestinal complications. Thirteen operative procedures were required in 8 patients. Operations included colon resection with colostomy (n=4), exploratory laparotomy with loop jejunostomy (n=l), antrectomy with Bilroth II anastomosis and cholecystostomy (n=l), drainage of a falciform ligament abscess (n=l), drainage and debridement of a perisplenic abscess with cholecystectomy (n=l), cholecystostomy (n=l), exploratory laparotomy (n=2), diagnostic laparoscopy (n=l), and femoral hernia repair (n=l). The operative mortality rate was 63% (5/8). Nineteen nonoperative complications were recognized and further subclassifie d into major and minor; the former of which included hyperammonemia (n=3), Ogilvie's syndrome (n=l), diverticulitis (n=2), reflux esophagitis (n=6), peptic ulcer disease (n=3), gastritis (n=4), gastrointestinal bleeding (n=2), CMV hepatitis (n=3), CMV colitis (n=l), choledocholithiasis (n=l), and C. difficile toxin positive diarrhea (n=7). Overall survival in patients with GI complications was 52% (12/23) compared to 77% (17/22) in patients without complications (p=0.176, NS). The vast majority of GI complications (74%) occurred within one month after transplantaiou. No significant correlation was found between GI complications and age, gender~ number of rejection episodes, outcome, time of transplantation (early versus recent), and primary disease. The only trends achieving statistical significanc e included time of transplantation and survival and age and survival, both of which failed to attain significance when tested with developing GI complications (p=0.20g, NS). Conclusions: GI complications are common postoperatively in lung transplantation patients, occurring in more than half of all patients. Since no precedent risk factors suggest which patients are likely to develop GI complications, clinicians must be alert to any warning signs and symptoms, especially during the first month after transplantation. Although the majority of complications were nonoperative and responsive to conservative therapy, there was a higher overall mortality rate for those patients requiring operative intervention, mandating an aggressive search for major, life-threatening complications in these immunosuppressed patients. A eQuality of Life Derived Benefit Score n and the evaluation of a procedure: the Pereutaneous Endoscopic Gastrostomy S.D. Lippe. J.G. O'Brien, C. Cook, LA. Balint. Division of Gastrnenterology and Center for Medical Ethics, Albany Medical Center, New York.

Abscess of the falciform ligament in a child with a ventriculoperitoneal shunt

Falciform ligament abscess resulting from an infected ventriculoperitoneal shunt has not previously been described. This unusual type of abscess should be considered in a patient with an infected ventriculoperitoneal shunt who presents with epigastric tenderness. Signs of peritonitis may not be present if the abscess is localized. Imaging studies such as ultrasound or CT scan may frequently establish the diagnosis.

Falciform ligament abscess in the infant

Two cases of abdominal abscesses related to the falciform ligament are described. The importance of ultrasonic localization is stressed, as these extrahepatic abscesses require surgical drainage, whereas an intrahepatic abscess, particularly amoebic, may be treated with antimicrobials.