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Aline Vaz da Silva1, Cristina Borges1, Vanda Pratas Vital1, Maria Knoblich1, Paolo Casella1

1- Serviço de Cirurgia Pediátrica, Departamento de Cirurgia, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central, EPE, Lisboa

- 15th European Congress of Pediatric Surgery
- Apresentação de poster

Aim: Accessory hepatic lobe (AHL) is a rare anatomical variant of the liver. It is usually asymptomatic but can also present acutelly due to torsion. Imaging results, namelly abdominal ultrasound and computer tomography, are frequently inespecific, with the diagnosis in most cases only being made intraoperativelly.
Method: retrospective review of a clinical case.
Results: 16-year-old otherwise healthy female presenting with three day history of increasingly severe epigastric pain that worsened with food intake, associated with anorexia and fever. Physical exam revealed epigastric tenderness with no peritoneal signs. Laboratory data showed elevated C reactive protein (CRP) (97mg/L) and mildly elevated alanine aminotrasnferase (36 U/L). Abdominal ultrasound (US) showed a heterogenenous lesion o f 43x22mm on the right aspect of the 1st and 2nd portion of the duodenum, as well as a small amount of free subhepatic fluid, wich could indicate a perfurated duodenal ulcer. Adbominal x-ray showed no pneumoperitoneum. Computed tomography with and without contrast enhancement showed a 5x4,5cm heterogeneous adjacente to the gallblader and extending to the hepatic hilum, with a small amount of free peritoneal fluid in the Douglas pouch. Laboratory exams where repeated, showing an increase in CRP (147,9mg/L). Due to worsening abdominal pain, increase in CRP and imaging suggestive of perfurated duodenal ulcer, it was decided to perform an upper gastrointestinal endoscopy in the operating theatre, and proceed to surgery according to findings. It revealed no alterations in the duodenum, except for a deformation in the anterior aspect of the second portion, probably due to extrinsic compression. It was decided to perform a laparotomy (midline supraumbilical incision), which revealed a pediculated lesion attached to the right hepatic lobe. The pedicle showed 540º torsion, causing congestion and infarction. After detorsion ischemic necrosis was evident, and the pedicle was ligated and ressected. Histological examination revealed liver tissue with congestion, hemorrhage and necrosis. The patient recovered uneventfully.
Conclusion: torsion of AHL is an extremely rare cause of abdominal pain, presenting with unspecific clinic and imaging. It should be kept in mind when epigastric pain is associated with imaging exams showing unclear perihepatic findings.

Palavras Chave: accessory hepatic lobe, duodenal ulcer