Agenesis of the right lobe of the liver: case report

Agenesis of the right lobe of the liver: a case report

INTRODUCTION

Agenesis of the right hepatic lobe is a rare congenital anomaly. Developmental anomalies of the right lobe of the liver were first reported in 1870 by Heller [6]. Anatomical variations of the liver are common, occur during the normal development of the organ, and correspond to variations in the distribution of liver territories. Agenesis of the right lobe of the liver is an incidental finding revealed by the popularization of ultrasonography, computed tomography, or magnetic resonance imaging due to the condition being asymptomatic.

CASE PRESENTATION

A 35-year-old Ethiopian female patient presented to the outpatient clinic with a complaint of right upper abdominal pain for 1 year, along with symptoms of fatty meal intolerance and long-standing epigastric burning pain. Her examination was unremarkable, and imaging investigations were suggestive of right hepatic lobe agenesis with multiple gallstones. Therefore, the patient was operated on and discharged with no perioperative complications.

CONCLUSION

Surgical understanding of such anatomical anomalies is necessary for surgical planning, the appropriate interpretation of intraoperative surgical findings, and the design of postoperative therapy. Here we report a case of right hepatic lobe agenesis with cholelithiasis and cholidocholithiasis and a brief review of right lobe agenesis in the literature.

Gallbladder volvulus with segmental right liver lobe hypoplasia/atrophy: a preoperative diagnostic dilemma

Gallbladder volvulus (GBV) due to rotation of the gall bladder (GB) around its own mesentery is a rare surgical emergency and often identified intraoperatively. Typically, cholecystitis is the initial clinical diagnosis, but a high index of suspicion on imaging can alert the physician for the possibility of GBV requiring urgent surgical intervention. We describe a case of a young female patient with hypoplasia/atrophy of the posterior segment of the right liver lobe and a GB with no hepatic attachments but only mesenteric pedicle. She presented with first episode of sudden-onset, severe right subcostal pain. The ultrasonogram and magnetic resonance cholangiopancreatogram findings were suggestive of GBV. She underwent laparoscopic exploration that confirmed GBV of a free-floating GB with a thrombosed cystic artery. The GB was detorted, and cholecystectomy was performed. She had an uneventful postoperative course and was discharged with no complications. Histopathological examination showed intramural haematoma of the GB with wall necrosis.

Developmental anomalies of the right hepatic lobe: systematic comparative analysis of radiological features

Aim

To investigate the radiological characteristics of developmental anomalies of the right hepatic lobe and to systematically compare the efficiency of CT, MR and ultrasound (US) imaging in revealing characteristics of these disorders.

Methods

This retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. CT, MR or US imaging and clinical data of 43 cases with developmental anomalies of the right hepatic lobe were independently reviewed by two experienced radiologists. Systematic comparative analysis of the CT, MR, and US imaging data indicating the main signs of right lobe aplasia or hypoplasia were obtained. Then, c2tests were performed to compare the results, considering P<0.05 as the significance threshold.

Results

Agenesis of the right hepatic lobe was observed in two cases. The main imaging features were agenesis of the right lobe and the absence of the right branch of the portal vein and hepatic artery, although one patient exhibited right diaphragm agenesis and a diaphragmatic hernia. Aplasia or hypoplasia of the right hepatic lobe was observed in 41 patients, and among these patients, the main radiological characteristics were as follows: right lobe volume reduction and stenosis of the right portal vein (41 cases, 100%), ectopic gallbladder (39 cases, 95%), left lobe hypertrophy (39 cases, 95%), left portal vein thickening (37 cases, 90%), dextral displacement of the first hepatic portal (32 cases, 78%), caudate lobe hypertrophy (16 cases, 39%), cholelithiasis (12 cases, 29%), portal hypertension (14 cases, 34%), tumor complications (11 cases, 27%), liver abscess (2 cases, 5%), concurrent intrahepatic bile pneumatosis (5 cases, 12%), dysplasia of the right hepatic bile duct (2 cases, 5%), and Budd-Chiari syndrome (2 cases, 5%). Comparative analysis of the main signs of right lobe hypoplasia revealed no significant difference in overall diagnostic efficiency between CT, MRI and US (CT VS MR, X2= 6.28, P = 0.985; CT VS US, X2= 11.2, P = 0.797; US VS MR, X2= 8.48, P = 0.903).

Conclusion

The main radiological characteristics of developmental anomalies of the right hepatic lobe were right lobe volume reduction, stenosis of the right portal vein, ectopic gallbladder, left lobe hypertrophy and dextral displacement of the first hepatic portal. By combining the data from imaging methods (CT, MRI, and US) with clinical data, developmental anomalies of the right hepatic lobe can be relatively accurately diagnosed. The results of this systematic comparative analysis may improve our understanding of this disease.

MR Imaging of Anomalous Lobes of the Liver

Four patients with anomalous lobes of the liver were observed at MR imaging. In one patient the anterior segment of the right hepatic lobe was absent and in 3 patients the left hepatic lobe was anomalous. The hepatic vasculature supporting the information of the anomalous hepatic lobes was well observed in all patients.

Biliary injury after cholecystectomy in a patient with severe right liver atrophy

We report a case of bile fistula after cholecystectomy in a patient with severe right liver atrophy, which was managed by endoscopic nasobiliary drainage and conservative treatment. The patient was a 76-year-old man with a sudden onset in the right flank and abdominal pain. Computed tomography revealed calculous cholecystitis and severely atrophied right lobe of the liver. Gallbladder was located in the superior-posterior portion of the liver as opposed to the normal position. The patient underwent cholecystectomy and showed massive bleeding and bile leakage at the gallbladder bed during operation. A bile fistula was detected three days after surgery, which was managed by interventional bile drainage. Right liver agenesis or severe atrophy is rare. Additionally, the report of combined bile duct injury after cholecystectomy in these settings is extremely rare.

Biliary injury after laparoscopic cholecystectomy in a patient with right liver agenesis: case report and review of the literature

INTRODUCTION

An 87-year-old man underwent attempted laparoscopic cholecystectomy.

MATERIAL AND METHODS

The procedure was characterized by significant inflammation and bleeding requiring conversion to an open procedure. Postoperatively, the patient had continued bile drainage from his surgical drain. He was referred to our institution and found to have complete transection of his common bile duct. Incidentally, he was noted on imaging studies to have absence of his right liver with associated left liver hypertrophy. This was characterized by complete absence of the right portal vein and right bile duct. Review of his preoperative imaging confirmed this finding of right liver agenesis and very unusual hepatic vein anatomy.

CONCLUSION

This represents the first reported case of bile duct injury in the setting of right liver agenesis. We review the details of the case and the natural history of agenesis of a hemiliver.

Agenesis of the right lobe of liver

Congenital anomalies involving the lobes of the liver are rare. Hypoplasia and agenesis occur more often in the left lobe. Agenesis of the right lobe is a rare anomaly with only about 42 cases reported in literature. In this communique we report one such case of agenesis of the right lobe of liver. A brief review of literature is made and its diagnosis and differential diagnosis are discussed.

Agenesis of the right lobe of the liver: report of a case

A case of congenital agenesis of the right lobe of the liver detected in a patient with gastric cancer is reported. The diagnosis of this rare anatomical variant was established by a combination of computed tomography, abdominal angiography, and operative findings. The importance of accurately recognizing this condition is stressed, and the clinical presentation, radiographic appearance, and differential diagnosis are also discussed.

Extreme right lobar atrophy of the liver: a rare complication of autoimmune hepatitis

Lobar atrophy is a rare morphologic change of the liver. We describe a 73-year-old woman with mild liver dysfunction and history of Sjögren's syndrome who had right hepatic lobar atrophy. Serum biochemistry levels were as follows: albumin, 4.5 g/dl; total bilirubin, 1.0 mg/dl; alanine aminotransferase, 25 international units/l; aspartate aminotransferase, 27 international units/l; alkaline phosphatase, 333 international units/l; and gamma-glutamyl transpeptidase, 332 international units/l. Serological data were as follows: rheumatoid factor, 27.9; anti-nuclear antibody, 1:640; and antismooth muscle antibody, 1:80. Viral markers for hepatitis B were all negative. Anti-hepatitis C virus (anti-c-100) was negative. Portal hypertension developed thereafter, and the patient died of hepatic failure at age 76. Postmortem examination revealed autoimmune hepatitis with moderate fibrosis, portal vein thrombus, and complete obstruction of the right hepatic duct due to hepatolithiasis. Terminal hepatic failure resulted from combination of decreased hepatic volume due to the right lobar atrophy, exacerbation of autoimmune hepatitis in the remnant left hepatic lobe, decreased portal venous blood flow due to thrombosis, portal hypertension, and cholangitis with hepatolithiasis. This is the first reported case of hepatic lobar atrophy due to autoimmune hepatitis. From a clinical standpoint, patients with hepatic lobar atrophy, even if asymptomatic, should be followed up with careful attention to progression of liver diseases, portal hypertension, and biliary complications.

Hypogenesis of right hepatic lobe accompanied by portal hypertension: case report and review of 31 Japanese cases

We report a rare case of hypogenesis of the right lobe of the liver with portal hypertension and a review of 31 cases of agenesis or hypogenesis of the right hepatic lobe reported in Japan. A 74-year-old man consulted our hospital for further examination after a mass screening for gastric cancer. On physical examination liver enlargement was palpable, but liver function tests were normal. Abdominal ultrasonography, computed tomography, technetium-99m liver scintigraphy, and endoscopic retrograde cholangiopancreatography revealed a small right hepatic lobe and moderate splenomegaly, in contrast to a hypertrophic lateral segment of the left hepatic lobe, as well as ectopic dislocation of the gallbladder. Endoscopic examination revealed esophageal varices, indicating portal hypertension. Abdominal angiography demonstrated mild shunt flow between the hepatic artery feeding from the gastroduodenal artery and the portal vein. A biopsy specimen taken from both lobes of the liver showed normal liver tissue histologically. Based on these findings, we made a definite diagnosis of hypogenesis of the right lobe of the liver with portal hypertension. The present case appears to be the first such case accompanied by portal hypertension reported in Japan.

Radiographic features of lobar agenesis of the liver

PURPOSE

Our aim was to describe the radiographic features of lobar agenesis of the liver.

MATERIAL AND METHODS

Six patients with lobar agenesis of the liver, 5 right- and one left-sided, are presented. CT was used to confirm diagnosis. Chest radiography, barium meals, and urograms were also analyzed.

RESULTS

In right-sided agenesis, the following were observed: a) hammock or U-shaped deformity of the stomach; b) colonic interposition of the diaphragm (Chilaiditi's syndrome); and c) reversal of the cranial orientation of the colonic hepatic flexure compared to the splenic flexure. The right kidney was higher in position than the left in both right- and left-sided lobar agenesis.

CONCLUSION

Our radiographic findings can provide a multidisciplinary approach in the identification of this anatomic anomaly.

Suprahepatic gallbladder and right lobe anomaly of the liver in patients with biliary cancers

The suprahepatic region is a rare ectopic location of the gallbladder. It usually combines with right lobe anomaly of the liver. Here we report two unusual cases of suprahepatic gallbladder with agenesis or hypogenesis of the right lobe of the liver and biliary cancer. A patient with a gallbladder tumor was admitted to our emergency room with acute cholecystitis and liver abscess. Imagining examinations and operation confirmed the suprahepatic position of gallbladder, agenesis of the right lobe, and dissemination of gallbladder cancer. In the patient with cholangiocarcinoma, CT scans and percutaneous transhepatic cholangiography documented the presence of a hilar tumor and hypogenesis of the right lobe. Both of these patients died from biliary tract cancer soon after operation.

Right hepatic lobe agenesis associated with bile duct carcinoma

A patient with obstructive jaundice was found to have bile duct carcinoma and right hepatic lobe agenesis. The diagnosis was made by computed tomography (CT), cholangiography, and angiography. Right hepatic lobe agenesis is a rare anomaly and has never been previously reported with bile duct carcinoma. CT cholangiography was critical in diagnosing the morphologic anomalies of the bile duct in this case.

Hypoplasia of the right hepatic lobe with ectopy of the gallbladder

Two cases of hypoplasia of the right hepatic lobe with gallbladder ectopy, which were diagnosed by computed tomography, are reported here. In each patient, the left hepatic lobe was enlarged. The gallbladder was located in the inferior portion of the liver in one patient and immediately below the right hemidiaphragm in the other. No other anomalies complicated these two cases. It should be kept in mind that hepatic lobe anomalies may have associated ectopy of the gallbladder.