Hepatic round ligament necrosis: A report of two cases managed differently

Abstract

Introduction and importance

Hepatic round ligament necrosis is a rare condition that has atypical clinical presentation. Its diagnosis; however, being a combination of clinical and biological signs, is very dependent on the computed topography scan.

Case presentation

This report demonstrates 2 cases that had different presentations. Case 1 was an elderly female with multiple comorbidities presenting with signs of sepsis, perturbation of liver enzymes and presence of thrombosis of portal vein as well as dilatation of bile ducts. On the other hand, case 2 was a younger male patient presenting with inflammatory syndrome, no other biological abnormalities and only an evident fatty stranding in his radiological workup.

Clinical discussion

Our 2 cases had different presentations in severity and were thus treated differently. The first patient had clinical, biological and radiological signs of severity; thus, he was treated surgically. On the other hand, the other patient with benign presentation was treated medically with antibiotics.

Conclusion

In the absence of recommendations concerning the management of hepatic round ligament necrosis, we suggest that treatment choice be based on the severity signs being: clinical, biological or radiological.

Highlights

• •Hepatic round ligament necrosis is a rare etiology of abdominal pain.
• •Presentation is atypical thus diagnosis is dependent on Computed Tomography scanner.
• •Management could be conservative by medical treatment or surgical depending on the severity.

Abbreviations

HRL

Hepatic Round Ligament

CT

Computed Tomography

MRI

Magnetic Resonance Imaging

EUS

Endoscopic Ultrasound

GGT

Gamma-glutamyl transferase

1. Introduction

The hepatic round ligament (HRL)- also called ligamentum teres hepatis, is a remnant of the left umbilical vein atresia [1]. Anatomically, it starts from the anterior side of the abdominal wall on the right side of the midline and ends at the level of the left portal vein. Surgically- speaking, the HRL is the first structure encountered when performing laparotomy, hence it can serve as an incision guide. Moreover, it has a wide clinical application [2]. For instance, it can be used as a landmark for dissecting the left hepatic duct, covering the gallbladder bed or pancreas, liver or even the spleen. Furthermore, it can be used for portal vein arterialization or embolization or the treatment of portal hypertension. Technically- speaking, it can also be used in different hepato-biliary surgeries as in the repair of bile ducts or venous repair [2]. Although this structure seems with no clear function, it can pose clinical problems. One of these pathologies concerning the HRL is necrosis presenting as abdominal pain. Due to the rarity of this entity, we decided to report 2 cases that we managed differently. The cases were reported in accordance with the SCARE criteria 2023 [3].

2. Cases

2.1. Case 1

A case of 82-year-old female known to have hypertension, hysterectomy, and appendicectomy presenting to the emergency department with abdominal pain. The pain was epigastric, abrupt in onset, deep in character, not associated with change of bowel habits or nausea. Furthermore, the pain did not depend on movement or other alleviating factors. The patient was afebrile with stable vital signs. In the emergency department, she had blood tests showing increase in inflammatory markers (C- reactive protein and leucocytes) with perturbation of hepatic enzymes in the form of cytolysis and cholestasis. Interestingly, she had her lipasemia at 34,000 U/L. Moreover, the patient had undergone a Computed Tomography (CT) scanner of the abdomen and pelvis showing peritoneal effusion- low in quantity, dilatation of the intrahepatic and the extra hepatic bile tracts. Moreover, it showed thrombosis of the portal vein at its bifurcation in the liver, as well as fatty stranding around the round ligament of the liver associated with hepatic perfusion disorder (Fig. 1). The patient was hospitalized in the surgery department for management. Our differential diagnosis was acute cholangitis secondary to cholelithiasis or tumor. Biliary Magnetic Resonance Imaging (MRI) was done to analyze the biliary tree. It showed dilatation of the bile ducts with no obstacle. In addition, and after discussion with the gastroenterology team, we opted for Endoscopic Ultrasound (EUS). It ruled out any tumor at the level of the pancreas or the ampulla of Vater or any other evident lesion. Notably, the patient received broad-spectrum antibiotics and anticoagulant at therapeutic doses. Despite the medical management, the patient had persistent increase in inflammatory markers and we decided to intervene with exploratory laparoscopy. During the exploration, we ruled in the diagnosis of necrosis of the HRL. Decision on the excision of the HRL was taken along with the falciform ligament and the specimen was sent to pathology for examination (Fig. 2). The post operative stay was favorable; the patient was clinically asymptomatic and he had amelioration in the inflammatory markers and the hepatic workup. Moreover, a CT scan was done 1 week after the operation, before discharging the patient home. It showed a collection without signs of abscess at the level of the resected round ligament, in addition to the amelioration in the dilatation of the bile ducts. Not to mention that the thrombosis of the portal vein decreased in extension. Post operative consultation was planned 3 months later with a CT scan of evaluation. The patient was asymptomatic and the scanner showed a decrease in size of the collection and was evident for persistence of bile ducts dilatation along with the portal vein thrombosis which was only noticed at the level of the left portal vein (Fig. 3). The pathology report evidenced cysto-steatonecrosis of fibro-adipose tissue without signs of malignancy. At 6 months post operatively, the patient was reseen with another CT scanner. This time the portal vein was revascularized and the collection has diminished by more than 70 % of its initial size. However, dilatation of the bile ducts was still marked.

Fig. 1.

CT scan of the abdomen in coronal and axial cut portal phase showing peritoneal effusion (red arrow), dilatation of the bile ducts intra and extra hepatic (yellow arrows), thrombosis of the vein port (blue arrow) and the inflammation represented by the fatty stranding at the level of the HRL and the falciform (green arrows). CT: Computed Tomography. HRL: Hepatic Round Ligament. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

Fig. 2.

Images during laparoscopy showing the HRL (A) being inflamed, the stomach (B), the abdominal wall (C) and the liver (D) from different angles. The circle shows the necrotic tissue after dissecting the HRL. HRL: Hepatic Round Ligament.

Fig. 3.

CT scan of the abdomen in axial cut portal phase at 3 months of the event. Image A shows cystic formation at the level of the resected HRL (orange arrow). Image B shows the reperfusion of the portal vein (blue arrow). CT: Computed Tomography. (For interpretation of the references to colour in this figure legend, the reader is referred to the web version of this article.)

2.2. Case 2

A case of 49 years old male known to have ischemic cardiovascular accident in the context of patent foramen ovale in 2007. He was treated by Acetylsalicylic acid 75 mg for this pathology, Atorvastatin 20 mg for dyslipidemia, and Mirtazapine for depression. Furthermore, the patient presented to the emergency room with abdominal pain without associated symptoms. Regarding his vital signs, the patient had low grade fever with stable blood pressure and pulse. On physical examination, we noticed abdominal obesity without scars. Abdomen was soft with epigastric tenderness. Notably, Muphy sign was negative. Furthermore, blood tests were positive for mild inflammatory markers with C-reactive protein at the upper edge of its normal level. On the other side, the pancreatic and liver enzymes were normal except for GGT (Gamma-glutamyl transferase) which was at 88 IU/L. It is noteworthy to mention that the increase in GGT was observed 1 year before this episode. CT scan was requested to rule out acute cholecystitis. Interestingly, inflammation was restricted to the round ligament with no other significant findings as shown in (Fig. 4). We were comfortable treating this patient by conservative approach. Precisely, the patient was hospitalized for monitoring and hydration in addition to antalgics. Theoretically, entity implies bacterial translocation to the round ligament, hence we prescribed Amoxicillin/Clavulanic Acid 1 g x3 per day for one week. At day 1 of hospitalization, the patient was asymptomatic and the inflammatory markers decreased. Hence, he was discharged with a course of antibiotics and antalgics. Follow-up with a CT scan of the abdomen was assigned in 1 month. Indeed, the patient was seen 1 month after the episode and the scan results were strictly negative for complications as in abscess, collection or thrombosis.

Fig. 4.

CT scan of the abdomen in axial and sagittal cut portal phase. Images A and B show the inflammation at the level of the HRL (arrow). CT: Computed Tomography. HRL: Hepatic Round Ligament.

3. Discussion

Necrosis of the HRL is a difficult diagnosis to establish due to its rarity and the unspecific clinical presentation. In 2020 a review of the literature concerning this entity done by Astha et al. found that both males and females are equally affected [4]. It was shown that the mean age for encountering this disease is 59.5 years old. However, the pathophysiology remains unclear, it was reported that digestive infection can contaminate the RL through permeable umbilical vein [5]. Another theory was ischemia similar to the pathophysiology of appendagitis [5]. Interestingly, the necrosis of the RL is most commonly misdiagnosed with acute cholecystitis [4]. On clinical level, it was reported that necrosis of the HRL can mimic pancreatitis; for Rui et al. showed in 2023 that a patient can present with typical abdominal pain with biological tests in favor of pancreatitis [1,5]. Another report from Tunisia showed that necrosis of the HRL can accompany acute cholecystitis, in which authors opted for cholecystectomy as well as resection of the HRL after confirming the diagnosis per operatively [6]. In addition, a previous report showed that the HRL can undergo torsion thus resulting in acute abdominal pain necessitating medical care [7].

Nevertheless, the diagnosis of HRL necrosis can be achieved thanks to CT scan of the abdomen. The latter helps in evaluating the severity of the disease. Furthermore, management is vague and some authors opt for surgical intervention as a primary resort [5]. By reviewing the literature, we were able to identify a few articles indexed on PubMed related to its management. In 2020, a report showed that the majority of cases were treated surgically as our first case and only few were managed medically as our 2nd case [4]. Regarding our cases; in the first case and due to the severity represented by high inflammatory markers, perturbation of liver enzymes and the presence of thrombosis of the portal vein, we opted for surgical management. Moreover, the patient of case 1 was a high- risk patient being elderly with multiple comorbidities. So, opting for surgical intervention was the most appropriate choice. On the other hand, the patient of case 2 was relatively young without comorbidities. Not to mention that his biological workup was relatively tolerable as well as his scanner was restricted to fatty strandings around the round ligament. Hence, opting for a conservative treatment seemed to be justifiable. Precisely and in the absence of clear pathophysiology, we adhere to the theory of bacterial translocation and hence we suggest adding antibiotics when conservative treatment is adopted. Resection for the HRL is sometimes associated to cholecystectomy [5], although no recommendations are available.

4. Study limitations

Our study is only a case report that highlights the need to have more studies to endorse our approach to treating this pathology.

5. Conclusion

HRL necrosis poses diagnostic challenges, yet its management seems more complicated. This study is the first that proposes a strategy for management. We suggest treating this entity based on the severity. Notably, severity can be divided into clinical, biological and radiological categories. Our cases suggest that mild cases can be treated conservatively; however, severe cases can be treated surgically.

Institute

Macon Hospital.

Ethical approval

Written informed consent was obtained from the patients for publication of this case report and the accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Funding

None.

Author contribution

Writing the paper: Alaa Kansoun.

Data collection: Alaa Kansoun.

Interpretation: Alaa Kansoun.

Supervision: Pierre Bernard.

Guarantor

Alaa Kansoun.

Research registration number

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Conflict of interest statement

None.