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Case series

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For citation purposes: Baruah P, Choudhury PR. Tongue-like elongation of the left lobe of liver. OA Case Reports 2013 Dec 24;2(17):161. Co

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Tongue-like elongation of the left lobe of liverP Baruah, PR Choudhury*

Abstract Introduction The liver is the largest gland in our body. Liver normally has a larger right lobe and a smaller left lobe. Though the tongue-like projection of the right lobe of the liver, i.e., Riedel’s lobe, is commonly found in literature, the left lobe has very few literature. In foetal life, the left lobe is nearly as large as its right and as the haematopoietic activity of the liver is assumed by the spleen and bone marrow, the left lobe undergoes some degen-eration. This paper discusses the tongue-like elongation of the left lobe of the liver. Case series Three livers with tongue-like elonga-tion of the left lobe were found during routine dissections of 20 cadavers in the Department of Anatomy, Gauhati Medical College, Guwahati. On exam-ination, the colour, consistency, and texture of the elongated parts were found to be similar to normal livers and histological examination showed normal liver tissue. There was ab-sence of fibrous tissue, so the elon-gated parts were not the appendix of the liver. Other parts of the liver were normal. ConclusionThis type of elongation of the left lobe of the liver may cause symptoms like pressure, pulling and pain in the epigastrium. Moreover, knowledge of this type of liver anomalies will be helpful for surgeons in planning hepato-biliary surgeries.

IntroductionThe liver is one of the most pre-cocious embryonic organs and is the centre of haemopoiesis in the foetus. It develops from an endo-dermal evagination of the foregut and from the septum transversum mesenchyme. The liver is propor-tionately large during its develop-ment. At three months of gestation, the liver almost fills the abdominal cavity and its left lobe is nearly as large as its right. When haematopoi-etic activity of the liver is assumed by the spleen and bone marrow, the left lobe undergoes some degenera-tion and becomes smaller than the right1.

According to Barclay-Smith, “The changes which the liver undergoes during growth require elucidation. The small size of the left lobe in the adult as compared with an early condition may be either due to its

relatively slow growth or to an actual atrophy of liver substance”2.

Anomalies of hepatic morphology, as opposed to anatomical variations, are rare. Nevertheless, knowledge of such anomalies is important since they do not always remain clinically latent. A general review of hepatic anomalies can be divided into two categories, i.e., anomalies due to de-fective development and anomalies due to excessive development of the liver3.

Riedel’s lobe was first recognised as an anatomical variant of the liver4, consisting of an inferior extension of the right lobe of the liver. Variants of anatomy of the left lobe of the liver are less recognised.

Congenital deformities of the liver confined to the left lobe are suffi-ciently extensive to cause symptoms5.

Bismuth-Couinaud segment II is commonly elongated. In segmental

* Corresponding author Email: [email protected]

Department of Anatomy, Fakhruddin Ali Ahmed Medical College, Barpeta, Assam, India Figure 1: Abnormal liver no.1 with elongated left lobe.

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The elongated parts were flat-tened above downwards. Colour, consistency, and texture of the elon-gated parts were found to be simi-lar to that of normal livers. Various parameters were recorded with measuring tape and tabulated along with the parameters of the normal livers (Tables 1, 2, 3 and 4). Histo-logical studies showed normal liver tissue in the elongated parts (Fig-ure 4). Other parts of the abnormal livers were normal in appearance. Neighbouring structures of the ab-normal livers (e.g. spleen, pancreas etc.) were also found normal during dissection.

DiscussionThe branches of the portal vein and tributaries of the hepatic veins are more numerous before birth, after which they are reduced by fusion or degeneration. The foetal portal vein joins the umbilical vein in a smooth right-hand curve, maintained after birth, with a sharp angle between the portal trunk and its left branch; the left vascular lobe may therefore

falciform ligament anteriorly and superiorly and through the groove for ligamentum venosum and teres hepatis inferiorly. These three livers were also compared with normal liv-ers of similar size, shape, and weight. Tissues of both elongated and nor-mal parts of the left lobes of each of the livers were taken for histological study under a light microscope after routine H&E staining.

liver anatomy, centrally located in each of the hepatic segments is a seg-mental branch of the portal vein and hepatic artery, as well as a segmental bile duct. The solitary distal hepatic veins lie between the individual seg-ments6,7. In this paper, we discuss a tongue-like elongation of the left lobe of the liver.

Case SeriesThree livers with tongue-like elonga-tion of the left lobes were found af-ter dissection of 20 cadavers in the Department of Anatomy, Gauhati Medical College, Guwahati, during 2010–11. The livers were taken out and preserved under 10% formalin for further study.

On gross examination, the colour, consistency, and texture of the elon-gated parts were studied and vari-ous parameters (length, breadth, thickness) were measured (taking arbitrary points) under daylight (Figures 1, 2 and 3). The arbitrary points were taken at the base, mid-dle, apex of the elongated parts, at the tuber omentale, at the upper end of the left lip of the groove for liga-mentum venosum, and at the lower end of the left lip of the groove for ligamentum teres hepatis. Fixed planes for divisions of the left and right lobes of the liver were con-sidered, which passed through the

Table 1 Measurements of left lobe of abnormal liver no.1 and normal liver

Measurements Abnormal liver No.1

Normal liver of similar weight

and sizeFrom upper end of left lip of groove for liga-mentum venosum up to apex of left lobe

10.7 cm 6.7 cm

From lower end of left lip of groove for liga-mentum teres up to apex of left lobe

17.5 cm 14.7 cm

From tuber omentale to apex of left lobe 11.2 cm 8.4 cmSum 39.4 29.8Mean 13.133 9.933S.D ±3.790 ±4.215S.E.M ±2.188 ±2.433

Figure 2: Abnormal liver no.2 with elongated left lobe.

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distention and the exact relation of the tongue-like elongation of the organ at the time of operation. The length of the lobe from the free mar-gin of the liver to its apex was six and one-quarter inches; width, one and three-quarters inches’5.

Hammond also mentioned that, ‘There is no doubt but that this is a true case of congenital elongation of the left lobe of the liver.’ ‘It is further shown by numerous autopsies that when the left lobe is deformed, it is usually folded upon itself and more or less incurved’5.

‘Following splenectomy, the liver can change its position and shape. Migration of the left lobe of the liver into the splenic bed in the left up-per quadrant is often seen by sur-geons immediately after removal of the spleen’9. In the present study, the spleen is normal in all the three cadavers.

‘The characteristic features of a tongue-like projection of the left lobe of the liver in a female adult, accompanied with a large lienore-nal venous shunt and intrahepatic anastomosis of the hepatic arteries, are described’, as reported by Chiba, Suzuki, Kasai10.

‘A computed tomography (CT) scan was performed which confirmed a congenital variant of the left lobe of the liver; the left lobe extending

age, for a painless tumorous disten-tion of the epigastrium, which she had noticed for nine years, though she had been suffering from spells of distressing discomfort at times for only about two years. On operation, the left lobe of the liver extended entirely across the lesser curvature into the left hypochondrium, where it was flattened out at the extremity over the spleen. The photograph and coloured plate show the tumorous

be at a circulatory disadvantage and unable to keep pace in growth with the right8.

At the left end of the adult left lobe, a fibrous band (fibrous appendix of liver) may appear as an atrophied remnant of the more extensive part of the left lobe found in children8. But in the present study, the histology of the elongated parts of the left lobes showed the central vein with radi-ating liver cells and absence of any fibrous element; excluding the pos-sibility of being appendix of the liver.

Congenital deformities of the liver confined to the left lobe, sufficiently extensive to cause symptoms, must be instructive, since careful search of the literature discloses the record of one case that, in any way, could be re-garded analogous5. Symptoms in this case were, pressure, pulling, and pain in the epigastrium5.

Congenital changes in the form of an enlargement of the left lobe are greater than what may occur in the right5.

Levi Jay Hammond reported in ‘congenital elongation of the left lobe of the liver’, that ‘a girl 16 years of

Figure 3: Abnormal liver no.3 with elongated left lobe.


Measurements Abnormal liver No. 2


and sizeFrom upper end of left lip of groove for ligamen-tum venosum up toapex of left lobe

13.9 cm 6.8 cm

From lower end of left lip of groove for ligamen-tumteres up to apex of left lobe

24.3 cm 21.2 cm

From tuber omentale to apex of left lobe 20.3 cm 7.9 cmSum 58.5 35.9Mean 19.5 11.967S.D ±5.246 ±8.015S.E.M ±3.029 ±4.628

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lateral segment (Bismuth-Couinaud segment II) of the left hepatic lobe, which can extend into the left up-per abdominal quadrant and even-tually abut or even wrap around the splenic contour. This anatomic vari-ant is more common in women than in men12.

The embryological basis for small-er size of the left lobe is that the haematopoietic function of the liver diminishes sufficiently in the last two months of pregnancy. This is associ-ated with the progressive reduction of its size which mostly affects the left lobe, as explained by Datta13.

Defective development of the left hepatic lobe can lead to gastric vol-vulus. Conversely, defective develop-ment of the right lobe of liver either remains clinically latent or leads to portal hypertension. The origin of the anomalies of hepatic morphology oc-curring in the course of organogene-sis remains to be elucidated. The use of imaging now allows identification of such anomalies prior to the occur-rence of an acute complication3.

Sethi has stated that, there was en-largement of the left hepatic lobe in a hypoplastic right hepatic lobe liver. In the present study, the right lobe was normal in all the three livers14.

The hepatic lobe anomaly is not al-ways congenital. Therefore, the diag-nosis of this anomaly requires other things such as no evidence of liver dysfunction15.

So, it is especially important to keep in mind these liver anomalies in the correct preoperative diagno-sis, because it will be helpful for the surgeon in planning biliary surgery or a portosystemic anastomosis15.

ConclusionPatient with tongue like elongation of left lobe of liver may present asymp-tomatically or with non-specific abdominal or epigastric pain and may present in adulthood. So in this type of anomalies imaging is recom-mended for proper diagnosis and management.

According to Haaga et al., common normal variants in liver morphology include horizontal elongation of the

posteriorly and lateral to the spleen,’11 as reported by Dunlop and Evans.

Table 4 Weights of three abnormal livers and normal liversWeight of abnormal liver Weight of normal liver of similar size

Liver No.1 908.6 gm 922.4 gmLiver No.2 1220.5 gm 1253.7 gmLiver No.3 570 gm 593 gm

Figure 4: Photomicrogarph of elongated part of left lobe of abnormal liver no.1.


Measurements Abnormal liver No.3


and sizeFrom upper end of left lip of groove for ligamen-tum venosum up toapex of left lobe 10.5 cm 4.3 cm

From lower end of left lip of groove for ligamentu-mteres up to apex of left lobe 16.8 cm 15.3 cm

From tuber omentale to apex of left lobe 13 cm 5.4 cmSum 40.3 25Mean 13.433 8.333S.D ±3.172 ±6.058S.E.M ±1.832 ±3.498

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Okajimas Folia anat Jpn. 1991 May; 68(1):51–6.11. Dunlop DG, Evans RM. Congenital abnormality of the liver initially misdiag-nosed as splenic haematoma. J R Soc Med. 1996 Dec;89(12):702–4.12. Haaga JR, Dogra VS, Forsting M, Gilke-son RC, Ha HK, Sundaram M. CT and MRI of the whole body in gastrointestinal im-aging. 5th Edn. Vol.2. Philadelphia: Mosby Elsevier; 2009. p.1458.13. Datta AK. Essentials of human embry-ology in the alimentary system. 6th edn. Kolkata, India: Current Books Interna-tional, 2010. p. 132.14. Sethi SK, Solanki RS. A case report hy-poplastic right hepatic lobe a rare anom-aly. Abdomin Imag. 2004;14(1):53–54.15. Aktan ZA, Savas R, Pinar Y, Arslan O. Lobe and segment anomalies of the liver. J Anat Soc India. 2001 Jan;50(1):15–16.

of the whole body in gastrointestinal im-aging. 5th edn. Vol. 2. Philadelphia: Mos-by Elsevier; 2009. p. 1456.7. Haaga JR, Dogra VS, Forsting M, Gilke-son RC, Ha HK, Sundaram M. CT and MRI of the whole body in gastrointestinal im-aging. 5th Edn. Vol.2. Philadelphia: Mos-by Elsevier; 2009. p. 1458.8. Williams PL, Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ. Gray’s Anatomy. In Alimentary system, 38th edn. Edinburgh, London, Newyork, Philadelphia, Sydney, Toronto: Churchill Livingston; 1995. p. 1801–2.9. Custer JR, Shafer RB. Changes in liv-er scan following splenectomy. J Nucl Med. 1975 Mar;16(3):194–5.10. Chiba S, Suzuki T, Kasai T. A tongue-like projection of the left lobe in human liver, ac-companied with lienorenal venous shunt and intrahepatic arterial anastomosis.

References 1. Standring S. Gray’s Anatomy. Pelvic gir-dle and lower limb, 40th edn. Edinburg, London, New York, Oxford, Philadel-phia, St. Louis, Sydney, Toronto: Elsevier Churchill Livingstone, 2008. p. 1207–8.2. Barclay-Smith E. A liver exhibiting Multiple Anomalies. J Anat Physiol. 1909 Jul;43(Pt 4):346–8.3. Champetier J, Yver R, Letoublon C, Vi-gneau B. A general review of anomalies of hepatic morphology and their clinical im-plications. Anat Clin. 1985;7(4):285–99.4. Firkin BG, Whitworth JA. ‘Riedel Lobe’. Dictionary of Medical Eponyms. London: Parthenon Publishing, 1987. 5. Hammond LJ. Congenital Elongation of the Left Lobe of the Liver. Ann Surg. 1905 Jan;41(1):31–5.6. Haaga JR, Dogra VS, Forsting M, Gilke-son RC, Ha HK, Sundaram M. CT and MRI

Table 5 Parameters of elongated part of left lobe of three abnormal livers

Measurements of the elongated parts Abnormal liver no.1 Abnormal liver no.2 Abnormal liver no.3

Length from mid-point of the arbitary base to the apex of elongated part 6.3 cm 13.8 cm 8.2 cm

Breadth

at the base 5.4 cm 7.5 cm 7 cm

at the middle 5 cm 6.8 cm 6.5 cm

near the apex 3.2 cm 5.2 cm 4.3 cm

Thickness

at the base 0.6 cm 1.2 cm 0.8 cm

at the middle 1 cm 1 cm 1 cm

near the apex 0.4 cm 0.5 cm 0.4 cm

Sum 21.9 36 28.2

Mean 3.129 5.143 4.029

S.D ±2.486 ±4.787 ±3.296

S.E.M ±0.939 ±1.809 ±1.246

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