The “sausage” abscess: abscess of the liagamentum teres hepatis

Abstract

An abscess of the ligamentum teres hepatis is a very rare cause of acute abdomen and can present a diagnostic dilemma. A 40-year-old diabetic male presented with obstructive jaundice and cholangitis. An ill-defined, sausage-shaped, tender parasagittal supraumbilical mass was palpable on the right side. Murphy’s sign was negative. Laboratory investigations revealed polymorphonuclear leukocytosis (total leukocyte count 19,000 mm–3), elevated alkaline phosphatase (400 IU l–1), conjugated hyperbilirubinaemia (16 mg dl–1) and elevated blood glucose (240 mg dl–1). Ultrasonography and MR cholangiopancreatography revealed cholecystolithiasis, obstructive choledocholithiasis, abscess of the ligamentum teres hepatis and left portal thrombosis. Under ultrasound guidance, pus was aspirated from the abscess and the patient was started on broad-spectrum intravenous antibiotics, insulin and low-molecular-weight heparin. He subsequently underwent endoscopic retrograde cholangiopancreatography with sphincterotomy and stone extraction. On the tenth day post admission, he underwent laparoscopic cholecystectomy and excision of the ligament. The patient made an uneventful recovery and was discharged on the seventh post-operative day. On follow-up, the patient remained asymptomatic with normal biochemical parameters. This article highlights the importance of suspecting and identifying an abscess of the ligamentum teres hepatis when a patient with acute abdomen presents with a sausage-shaped right parasagittal mass, especially in the setting of cholangitis, cholecystitis or omphalitis.

Abscess of ligamentum teres hepatis post-endoscopic retrograde cholangiopancreatography: A case report and a literature review

“…Of the 18 cases, 4 presented palpable/noticeable mass in the epigastrium. 9 , 12 , 19 , 21 The majority of cases are accompanied by at least one of these complications, pancreatitis, obstructive choledocholithiasis, cholangitis, and portal thrombosis. An LTH or FL abscess was first suspected in most cases by imaging and confirmed by intraoperative exploration followed by treatments.…”

“…Six patients were cured with conservative therapy, 7,10,14,20,21 while the rest underwent surgical resection, including some who received conventional treatment primarily but recurred or did not shrink the abscess. 8,9,11–13,15–19,22,23…”

“…Six patients were cured with conservative therapy, 7,10,14,20,21 while the rest underwent surgical resection, including some who received conventional treatment primarily but recurred or did not shrink the abscess. 8,9,[11][12][13][15][16][17][18][19]22,23 As such, scholars classify LTH abscess as a complication of biliary tract obstruction interpreted as retrograde infection of the portal venous system. 18,19,23 When bacteria invade the hepatic sinusoids and systemic circulation, they can cause abscesses in the round ligament of the liver.…”

“…7,8 However, conservative treatment with endoscopic biliary drainage and broad-spectrum antibiotics has also been effective in improving condition. 4,7,9,10 The latter can be considered the primary choice when the patient’s general conditions allow.…”

Abscess of the Ligamentum Teres: a Rare Entity

“…The ligamentum teres hepatis (LTH) is a remnant of the left umbilical vein and runs from the umbilicus to the liver. Abscess of the ligamentum teres hepatis is an extremely rare cause of acute abdomen, and it should be suspected in any sausage-shaped palpable epigastric mass with history of cholecystitis, omphalitis or cholangitis [ 1 ]. The pathogenesis happens due to portal pyaemia with subsequently infection to the falciform ligament via the paraumbilical veins.…”