Round ligament (liver) infiltration as the only radiological sign for an underlying cholangitis

M. Benoit, I. Rotas, D. Vo, B. Egger

Objective

Tumoral or infectious proximity infiltration of the round ligament of the liver has been published previously.

Methods

We present the case of a 45 year old male who was admitted with a history of jaundice during the past five days with discoloration of faces and urine as well as ongoing pain in the right upper abdomen. On examination the right upper abdomen was tender on palpation without any signs of peritonitis. Laboratory tests revealed a mild inflammation with a WBC of 10,9 G/l and a CRP of 62mg/l. Furthermore there were signs of cholestasis with a Bilirubin of 59mcmol/l, an Alcaline Phosphatase of 298U/I and a Gamma-GT of 512U/I. Upper abdominal ultrasonography was completely normal without signs of any gallbladder inflammation or stones present in the gallbladder and without dilatation of the common bile duct and biliary tree. CT scan revealed an infiltration of the round ligament of the liver, a strip of perivesicular free fluid and a slight enhancement of the common bile duct. MR imaging confirmed these findings. With the hypothesis of a beginning cholangitis an intravenous antibiotic treatment with co-amoxcicillin and a symptomatic treatment with painkillers were introduced. Following that the patient recovered rapidly and could be discharged home. At one month’s follow-up the patient was completely free of symptoms. Repeated CT scan demonstrated a marked decrease of the round ligament infiltration of more than 50%. Considering that the origin of the infection is most likely caused by the passage of a stone or sludge through the biliary tract an elective laparoscopic cholecystectomy has been performed with a completely uneventful follow-up.

Results

This case illustrates the appearance of an infectious infiltration of the round ligament of the liver due to an underlying infection of the biliary system.

Conclusion

Infiltration of the round ligament of the liver is a rare occurrence but may be the only radiological sign of an infection of the biliary system. Immediate antibiotic treatment is recommended to resolve the problem. Further investigations evaluating the cause of cholangitis is necessary and, as far as no other underlying reason is found, a passage of sludge or stones has to be suspected even without stones present in the gallbladder. In conclusion, an elective cholecystectomy is reasonable in such cases.