Question: A 35-year-old woman presented to the emergency department with a 1-day history of right lower quadrant pain. Her past medical history was notable for an omphalocele (requiring multiple abdominal surgeries as an infant) and antiphospholipid syndrome with multiple deep vein thromboses and pulmonary emboli. The patient described the abdominal pain as constant without radiation and unrelated to food intake. She denied any nausea, vomiting, fevers, chills, change in bowels, bleeding, or urinary symptoms. Laboratory data were unremarkable. Coronal and cross-sectional cuts from abdominal computed tomography (CT) are shown in Figures A and B, respectively. What is the diagnosis? Look on page 323 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. The CT scan depicted in Figure A revealed a hyperlucent right upper quadrant with multiple nondilated loops of large and small bowel. The kidneys, adrenals, and pancreas remained normal. Pelvic images revealed a deformed, malrotated ectopic liver with smooth margins. Incidental note was made of several hypodense round lesions consistent with hepatic adenomas. Of note, the portal vein was absent and the gallbladder (Figure B, black arrow) was entirely intrahepatic. Figure B further highlights the relationship of the liver to the uterus (white arrow). Hepatic venous drainage occurred via a long conduit to the right atrium. Hepar ambulens, or hepatic hypermobility, is generally caused by congenital laxity or maldevelopment of coronary and triangular suspensory ligaments, persistence of the ventral mesentery, and absence of tethering to the inferior vena cava.1Timpone V.M. Lattin Jr., G.E. Lewis R.B. et al.Abdominal twists and turns: part 2, solid visceral torsions with pathologic correlation.AJR Am J Roentgenol. 2011; 197: 97-102Crossref PubMed Scopus (3) Google Scholar Heister first described hepar ambulens in 1754. The majority of cases since have been attributed to colonic obstruction—particularly colonic volvulus.2Nichols B.W. Figarola M.S. Standley T.B. A wandering liver.Pediatr Radiol. 2010; 40: 1443-1445Crossref PubMed Scopus (10) Google Scholar Hepatic hypermobility remains an exceedingly rare finding with few reported cases to date. Mobility is typically limited to movement from the right to left upper quadrants and epigastric region. The CT scan presented from this case displays a striking image of hepatic hypermobility associated with congenital omphalocele. A maldeveloped hepatic fossa and elongated hilar structures presumably enabled hepatic migration into the pelvic region.3Puthenpurayil K. Blachar A. Ferris J.V. Pelvic ectopia of the liver in an adult associated with omphalocele repair as a neonate.AJR Am J Roentgenol. 2001; 177: 1113-1115Crossref PubMed Scopus (9) Google Scholar Loops of bowel may have returned to the right upper quadrant after surgical relocation of the liver into an under developed hepatic fossa and subsequently encouraged distal liver movement. We concluded that the malpositioned, deformed liver was a long-standing finding unrelated to the patient's chief complaint, given the normal hepatic enzyme levels with expected morphology and enhancement patterns. Although there may be a suspected increased risk for vascular torsion, all reported cases of hepar ambulens have been incidental with no symptomatology related to the condition.1Timpone V.M. Lattin Jr., G.E. Lewis R.B. et al.Abdominal twists and turns: part 2, solid visceral torsions with pathologic correlation.AJR Am J Roentgenol. 2011; 197: 97-102Crossref PubMed Scopus (3) Google Scholar The patient's organ growth has conformed to her pelvic shape, as evidenced by the entirely intrahepatic gallbladder and malrotated liver. The conformed liver seems to be anchored into the patient's pelvis, effectively limiting future mobility and does not warrant further surgical intervention at this time.