Torsion of a hypertrophic pedunculated caudate lobe of the liver in a 41-year-old woman: a case report
Adak Azdasht, Marit Kalisvaart, Peter Šandera, Matthias C. KöstersIntroduction:
Hepatic lobe torsion is an exceptionally rare surgical emergency, most commonly involving accessory hepatic lobes or the left hepatic lobe. Torsion of a pedunculated caudate lobe in an adult is exceedingly uncommon and may present a considerable diagnostic challenge because radiological findings can mimic other intra-abdominal pathologies.
Presentation of case:
A 41-year-old Caucasian woman with no relevant medical or surgical history presented with sudden-onset severe epigastric pain. Physical examination demonstrated localized epigastric tenderness without generalized peritonitis. Laboratory investigations, including complete blood count, inflammatory markers, liver function tests, coagulation profile, and serum lipase, were within normal limits. Contrast-enhanced computed tomography (CT) demonstrated a well-defined lesion adjacent to the celiac trunk with heterogeneous enhancement, raising suspicion of a hypervascular lesion such as a neoplasm. No specific radiological sign of torsion was identified preoperatively. As the lesion was located close to the stomach, upper gastrointestinal endoscopy was performed to exclude intraluminal gastric pathology but was unremarkable. Persistent severe pain requiring intravenous morphine prompted diagnostic laparoscopy. Initial inspection of the abdominal cavity revealed no obvious pathology because the caudate lobe, which had undergone torsion, was concealed within the lesser sac. Following division of the lesser omentum, a hypertrophic pedunculated caudate lobe that had undergone clockwise torsion around its vascular pedicle was identified. The devascularized lobe was resected laparoscopically using a Thunderbeat™ energy device and retrieved in an Endobag ® . Histopathological examination demonstrated hemorrhagic and ischemic necrosis without evidence of neoplasia. The postoperative course was uneventful. The patient was discharged on postoperative day 3 and remained symptom-free at the 6-week follow-up.
Clinical discussion:
Venous outflow obstruction caused by torsion may initially preserve partial arterial inflow, resulting in heterogeneous enhancement on contrast-enhanced CT and mimicking a hypervascular lesion. When imaging findings are inconclusive and severe symptoms persist, diagnostic laparoscopy enables definitive diagnosis, and minimally invasive treatment.
Conclusion:
Although exceptionally uncommon, torsion of a pedunculated caudate lobe should be considered in the differential diagnosis of unexplained acute upper abdominal pain with atypical imaging findings. This case highlights the importance of early laparoscopic exploration, enabling definitive diagnosis and successful minimally invasive treatment.