DOI:10.2214/AJR.05.0601
AJR 2007; 188:W331-W333
© American Roentgen Ray Society
Hepatocolonic Vagrancy: A Rare or Underrecognized Entity?
Rafael Fuentes1,
Jose M. Santana,
Patricia Alemán,
Jose C. Antela and
Ascension Jorrin
1 All authors: Department of Radiology, Hospital Universitario Insular de Gran
Canaria, Av. Marítima del Sur s/n, Las Palmas de G. C., Las Palmas
35016, Spain.
Received April 6, 2005;
accepted after revision June 24, 2005.
Address correspondence to J. M. Santana.
WEB This is a Web exclusive article.
Keywords: abdominal imaging • colon • gastrointestinal radiology • liver
Introduction
Hepatocolonic vagrancy is a rare entity consisting of excessive
mobility of the liver in the transverse plane. It is associated with colonic
fixation abnormalities, which cause repeated occlusive episodes. We present
the radiologic features of a new case of this entity, the seventh report of
this condition in the literature.
Case Report
A 72-year-old man was transferred to our emergency department with sigmoid
volvulus (Fig. 1A). He had had
repeated episodes of abdominal pain for several years. His condition had
always been labeled subocclusive crisis and had resolved spontaneously or with
conservative treatment.
Evaluation of two abdominal radiographs during follow-up revealed, to our
surprise, a shift of the hepatic shadow from the right to the left upper
quadrant. The time elapsed between the radiographs was 24 hours (Figs.
1B and
1C). The second radiograph was
obtained immediately after the patient awakened. He usually slept in the left
lateral decubitus position.
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Fig. 1C —72-year-old man with sigmoid volvulus. Abdominal radiograph obtained
24 hours after B shows hepatic shadow in left upper quadrant, cardiac
shadow on left side, and correct placement of nasogastric tube.
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One day later, abdominal CT (Figs.
1D,
1E,
1F and
1G) performed in both lateral
decubitus positions confirmed considerable mobility of the liver in the
transverse plane. When the patient was lying in the left lateral decubitus
position, the liver rotated clockwise and occupied the entire left
hypochondrium. Images with the patient in the right lateral decubitus position
showed the liver shifting to its normal anatomic position. No other organ
misplacement, intestinal malrotation, or other anomaly was noticed. The
patient did not report discomfort while under-going imaging or after staying
in the left lateral decubitus position for several hours.
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Fig. 1D —72-year-old man with sigmoid volvulus. CT scans obtained after
patient was lying in right (D and F) and left (E and
G) lateral decubitus positions confirm shift and clockwise rotation of
liver and portal vein (arrowhead, D), left portal vein
(black arrow, E), and gallbladder (arrowhead,
F and G). Spleen and retroperitoneal structures have not
shifted, including azygos vein (white arrow, E).
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Fig. 1E —72-year-old man with sigmoid volvulus. CT scans obtained after
patient was lying in right (D and F) and left (E and
G) lateral decubitus positions confirm shift and clockwise rotation of
liver and portal vein (arrowhead, D), left portal vein
(black arrow, E), and gallbladder (arrowhead,
F and G). Spleen and retroperitoneal structures have not
shifted, including azygos vein (white arrow, E).
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Fig. 1F —72-year-old man with sigmoid volvulus. CT scans obtained after
patient was lying in right (D and F) and left (E and
G) lateral decubitus positions confirm shift and clockwise rotation of
liver and portal vein (arrowhead, D), left portal vein
(black arrow, E), and gallbladder (arrowhead,
F and G). Spleen and retroperitoneal structures have not
shifted, including azygos vein (white arrow, E).
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Fig. 1G —72-year-old man with sigmoid volvulus. CT scans obtained after
patient was lying in right (D and F) and left (E and
G) lateral decubitus positions confirm shift and clockwise rotation of
liver and portal vein (arrowhead, D), left portal vein
(black arrow, E), and gallbladder (arrowhead,
F and G). Spleen and retroperitoneal structures have not
shifted, including azygos vein (white arrow, E).
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Discussion
The liver is usually situated in the right upper quadrant of the abdomen,
just below the diaphragm. Superior displa cement occasionally is seen in cases
of diaphragmatic herniation or eventration, ascites, abdominal tumors, and
extreme intestinal dilatation. Inferior displacement can result from
hepatoptosis, hepatodiaphragmatic interposition of the colon (i.e.,
Chilaiditi's syndrome), right subphrenic abscess, pulmonary emphysema, and
right pleural effusion. In some cases, the liver is congenitally situated in
an uncommon area, as in situs inversus, situs transversus, or congenital
ectopy.
Excessive mobility of viscera has been frequently documented. However, free
displacement of the liver in the transverse plane is a rarely seen condition
[1]. Several anatomic
structures contribute to fixation of the liver, such as the coronary,
triangular, and falciform ligaments; the hepatodiaphragmatic connective tissue
contained within the bare area; and the inferior vena cava. The estimated
relative importance of each structure is not well established. However, the
suprahepatic veins through which the liver is attached to the inferior vena
cava are accepted as the most prominent anatomic feature
[2].
In 1990, Siddins and Cade
[2] confirmed that all
previously recognized cases of wandering liver were associated with colonic
anatomic abnormalities such as zygotic failure and mesocolon redundancy. That
finding led those investigators to define hepatocolonic vagrancy syndrome,
which is characterized by transverse hypermobility of the liver, lack of
inferior vena caval tethering and obstruction, persistence of midline
falciform ligament and absence of a bare area, and associated peritoneal
reflections, such as the coronary and triangular ligaments
[2].
Striking and unexplained associations between colonic fixation and
abnormalities are apparent. Sigmoid mesocolic redundancy is associated with
volvulus [1,
2] and elongated transverse
mesocolon [3], and mobile
ascending and descending colon is associated with redundant transverse
mesocolon [4]. Such
associations are unlikely to be coincidental. As of this writing, only six
cases of this entity have been reported
[1-6],
five of them occurring in men. Abnormality in fixation of the liver makes the
organ hypermobile in the transverse plane, allowing full occupation of the
left upper quadrant with changing positions.
It is remarkable that despite the potential tendency for vascular torsion,
none of the patients described reported symptoms related to excessive mobility
of the liver [6]. It seems
reasonable to assume that hypermobile liver is an asymptomatic condition. It
may remain undetected for years until it becomes an incidental finding or the
liver is medially displaced as a result of distention of the right colon or
interposition of the sigmoid colon dilated owing to volvulus
[2]. All reported cases were
investigated because of symptoms related to obstruction of the
gastrointestinal tract, and all had associated elongation of the large-bowel
mesentery with a predisposition to volvulus
[6].
The limited number of existing references in the literature dealing with
hepatocolonic vagrancy hampers diagnosis of the condition. Therefore, most
cases are diagnosed in adulthood and accidentally, as in our case, in which
only thorough evaluation for imaging led us to obtain CT scans in both lateral
decubitus positions. In our estimation, cases of hepatocolonic vagrancy may
not be as unusual as previously thought. Thus awareness of this entity during
examinations of patients with recurrent subocclusive episodes or those with
large-bowel volvulus will favor diagnosis in the future.
References
- Cope E, Levy JI. Dislocation of the liver. S Afr Med
J 1966; 40:366
-369[Medline]
- Siddins MT, Cade RJ. Hepatocolonic vagrancy: wandering liver with
colonic abnormalities. Aust N Z J Surg1990; 60:400
-403[Medline]
- Sharov BK. Unusual case of hepar mobile (wandering liver) [in
Russian]. Vestn Rengenol Radiol 1960;35
: 63-64
- Chiavarini RL, Chang SF, Westerfield JD. The wandering gallbladder.
Radiology 1975;115
: 47-48[Abstract]
- Feins NR, Borger J. Torsion of the right lobe of the liver with
partial obstruction of the colon. J Pediatr Surg1972; 7:724
-725[CrossRef][Medline]
- al-Ali F, Macpherson RI, Othersen HB, Chavin KA. A "wandering
liver" in an infant. Pediatr Radiol1997; 27:287[CrossRef][Medline]
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Introduction
Case Report
