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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 148-149

Falciform ligament thrombosis: A rare cause of acute-onset pain in the right hypochondrium


Department of Radiology, Holy Family Hospital, Thodupuzha, Kerala, India

Date of Submission18-Apr-2019
Date of Decision28-Aug-2019
Date of Acceptance20-Sep-2019
Date of Web Publication8-Oct-2020

Correspondence Address:
Reddy Ravikanth
Department of Radiology, Holy Family Hospital, Thodupuzha, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_44_19

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How to cite this article:
Ravikanth R, Kamalasekar K. Falciform ligament thrombosis: A rare cause of acute-onset pain in the right hypochondrium. CHRISMED J Health Res 2020;7:148-9

How to cite this URL:
Ravikanth R, Kamalasekar K. Falciform ligament thrombosis: A rare cause of acute-onset pain in the right hypochondrium. CHRISMED J Health Res [serial online] 2020 [cited 2020 Oct 24];7:148-9. Available from: https://www.cjhr.org/text.asp?2020/7/2/148/297581



Sir,

A 44-year-old female presented with a 1-day history of sudden-onset pain in the right hypochondrium with associated vomiting. On admission, her vitals were normal: temperature (36.9°C), blood pressure (110/70 mmHg), heart rate (78 beats per minute), and alert and oriented. Abdominal examination revealed point tenderness in the right hypochondrium, no organomegaly, guarding, or rebound tenderness. Ultrasound abdomen revealed a linear echogenic structure with absent color flow arising from the segment IV and passing over the surface of left lobe, which was thought to represent an acute thrombosis of the umbilical vein [Figure 1]. However, the left portal vein branch was patent. The falciform ligament of the liver is a fibrous remnant of the obliterated umbilical vein. The umbilical vein and artery play a vital role during fetal growth. These structures allow the exchange of materials between fetal and maternal circulation. The umbilical vein divides into two structures at the liver (ductus venosus and a branch that communicates with the hepatic portal vein). During fetal development, the majority of oxygenated blood travels via the umbilical vein into the ductus venosus that subsequently drains into the inferior vena cava. When renal, pulmonary, and digestive functions begin to function at birth, the umbilical vein collapses and remains as the falciform ligament.[1] Falciform ligament thrombosis is a rare and poorly differentiated complication in cirrhosis and pancreatitis, which both clinicians and radiologists should be aware of.[2] In this setting, it is important to exclude falciform ligament thrombosis as a differential diagnosis in a patient with abdominal pain. The acute diagnosis can be well demonstrated on both contrast computed tomography (CT) and magnetic resonance imaging.
Figure 1: Longitudinal gray-scale ultrasound image demonstrating linear echogenic structure from segment IV and passing over the surface of left lobe representing thrombosed falciform ligament (arrows)

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Like other fatty appendages, the fatty appendages of the ligamentum teres have a fragile blood supply. When they twist, kink, or stretch transiently or permanently, the efferent vein may become thrombosed, giving rise to hemorrhagic infarction.[3] Patients present with abdominal pain and rebound tenderness that correlates with the location of the infarcted fat appendage, usually in epigastrium in the case of falciform ligament. Despite severe pain, laboratory tests are usually normal or with mild inflammatory changes. Clinical suspicion is usually gastroduodenal pathology, acute pancreatitis, and cholecystitis.[4] At ultrasonography, it appears as an oval echogenic, noncompressible mass at the point of maximal tenderness. Ultrasonography may be useful to demonstrate that the lesion does not move with breathing, due its superficial extraperitoneal nature.[5] Blood flow is typically absent on color Doppler, unlike other inflammatory conditions. The most common CT feature is an oval area of heterogeneous fat attenuation surrounded by a ring of soft tissue (hyperattenuating rim sign) that represents adjacent inflamed peritoneum, sometimes with a central area of high attenuation (central dot sign) due to venous thrombosis, associated to adjacent inflammatory changes.

The peculiarity of this case presentation is based on the fact that there has been acute thrombosis of the falciform ligament in a noncirrhotic liver with a patent portal venous system.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. 6th. Philadelphia, Pa, USA: Wolters Kluwer/Lippincott Williams & Wilkins; 2010.  Back to cited text no. 1
    
2.
Lim HQ, Lee XW, Mathias N. A rare finding of falciform ligament thrombosis as a sequel of acute pancreatitis. Case Rep Radiol 2017;2017:2879568.  Back to cited text no. 2
    
3.
Coulier B. Contribution of US and CT for diagnosis of intraperitoneal focal fat infarction (IFFI): A pictorial review. JBR-BTR 2010;93:171-85.  Back to cited text no. 3
    
4.
Justaniah AI, Scholz FJ, Katz DS, Scheirey CD. Perigastric appendagitis: CT and clinical features in eight patients. Clin Radiol 2014;69:e531-7.  Back to cited text no. 4
    
5.
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. 5
    


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