Bleeding Boundaries: The enigma of falciform ligament haematoma

A 93-year-old female with a medical history of pancreatitis and ischemic stroke presented to the emergency department with symptoms of coffee-ground vomiting and abdominal pain. On examination, she exhibited tenderness in the right hypochondrium region. Further laboratory tests revealed a serum amylase level of 960 U/L. It is important to note that the patient was taking warfarin, which was discontinued upon admission and there was no history of abdominal trauma.

In the CT abdomen conducted during the portal venous phase, there was evident enlargement of the falciform ligament. This enlargement was accompanied by fat stranding around the ligament, below the level of the liver edge. The expanded falciform ligament showed a lower density compared to the neighbouring liver tissue (Figures 1a, 1b and 1c).

MRI imaging also revealed an expansion of the falciform ligament, along with adjacent fat stranding in the infrahepatic region. The ligament appeared hypointense (dark) on T2-weighted sequences and hyperintense (bright) on fat-saturated T1-weighted sequences. Additionally, there was no enhancement observed on the post-contrast sequence. These findings indicate and verify the presence of a haematoma in the falciform ligament (Figures 2a, 2b, 2c and 2d).

The falciform ligament is a fibrous structure that connects the liver to the anterior abdominal wall [1]. It consists of two layers of peritoneum and contains the ligamentum teres hepatis and paraumbilical veins [2,3].

Haematoma of the falciform ligament is a rare occurrence, with few reported cases in the literature [2]. Symptoms include right upper quadrant pain, mass, nausea, and epigastric tenderness. The exact cause of spontaneous haematoma of the falciform ligament is not well understood but is believed to be associated with the use of anticoagulant medications [2]. The haematoma of the falciform ligament discussed in this case was hypothesised to be caused spontaneously by warfarin. The coffee-ground vomiting in the patient’s clinical history was thought to be due to a gastrointestinal bleed induced by warfarin. However, there was no contrast extravasation on CT abdomen to suggest this (Figures 1a, 1b and 1c). Despite the patient having a raised amylase of 960 U/L, the patient had no features suggestive of acute pancreatitis on CT or MRI imaging of the abdomen (all Figures).

Both ultrasound and CT can be used to differentiate between solid and cystic lesions of the falciform ligament, although they may not provide a definitive diagnosis [4]. Ultrasound is a cost-effective, safe, and easily accessible modality for detecting falciform ligament pathology [4]. CT is considered the best imaging modality for assessing falciform ligament pathology due to its ability to create high-resolution images with thinner slices and multiplanar reconstruction [1,5]. MRI, using fat suppression sequences, can also be useful in diagnosing falciform ligament pathologies by highlighting the difference between adipose tissue and blood. However, the susceptibility to motion artefacts during MRI scanning can limit its use in abdominal imaging [5].

The curative treatment for haematoma of the falciform ligament involves surgical excision [2]. Laparotomy, which allows for direct inspection of the abdominal cavity, can help clinicians reach a definitive diagnosis and exclude other intra-abdominal pathologies [4]. Surgical excision can be beneficial in cases of diagnostic uncertainty and provide symptomatic relief, especially when the condition mimics other serious medical conditions such as acute pancreatitis, perforated duodenal ulcer, or acute cholecystitis [3]. The patient did not require any further surgical intervention or imaging as she was stable following admission to the hospital.

Learning Points

1. The exact cause of falciform ligament haematoma is unclear, and spontaneous haemorrhage in the falciform ligament is extremely rare.
2. Haematoma of the falciform ligament should be considered as a possible, albeit rare, cause of acute abdomen, especially in patients prescribed anticoagulant medications.
3. Surgical excision is the curative treatment option, providing both diagnostic clarity and symptomatic relief.
4. ⁠Imaging modalities such as ultrasound, CT, and MRI can aid in the diagnosis, with CT being the preferred modality.

Written informed patient consent for publication has been obtained.