Journal of Gastrointestinal Surgery 28 (2024) 1000–1002

Contents lists available at ScienceDirect

Journal of Gastrointestinal Surgery

journal homepage: www.jogs.org

GI Image

Giant caudate lobe in secondary biliary cirrhosis

⁎
Alexandre de Hemptinne , Thomas Husson, Daniel Azoulay
]]
]]]]]]
]]

Centre Hépato-Biliaire Paul Brousse, Paris, France

a r t i cl e i nfo

Article history:
Received 18 February 2024
Accepted 19 February 2024
Available online 21 February 2024

Introduction edema. Laboratory tests showed a total bilirubin level of 240 μmol/L
(normal range, 3.4–20.5), a serum albumin level of 21 g/L (normal
The anatomy of the caudate lobe, also identified as hepatic seg­ range, 35–50), and a prothrombin time of 18% (normal range,
ment I, is intricate. The French surgeon and anatomist Claude 70–100).
Couinaud (1922–2008) delineated its structure into 3 divisions (the Computed tomography of the abdomen revealed hepatic dys­
Spiegel lobe, the paracaval portion, and the caudate process) using morphia with atrophy of right and left hepatic lobes and major hy­
portal segmentation as a basis. pertrophy of caudate lobe. Evidence of portal hypertension was also
This caudate lobe extends forward and to the sides of the ret­ observed including splenomegaly and mild ascites (Fig. 1).
rohepatic portion of the inferior vena cava, separating this vena cava
trunk from the rest of the liver. Its portal pedicles are numerous and
arise from the right and left portal branches, and its venous drainage
occurs through short hepatic veins draining directly into the inferior
vena cava.
Therefore, the anatomy of the caudate lobe is complex and
variable. With its unique and highly efficient inflow and outflow
systems, this posterior sector serves as a kind of backup liver. It helps
prevent hepatic failure in various situations owing to its autonomous
vascularization and considerable capacity for regeneration.
Hepatic cirrhosis in particular is among the liver pathologies in
which the caudate lobe can fulfill its compensatory role. Here, our
focus will be on secondary biliary cirrhosis, which arises from per­
sistent biliary obstructions, such as those seen in primary sclerosing
cholangitis.

Case report

We reported the case of a 16-year-old girl who was admitted to

the hospital because of weakness, abdominal pain, and jaundice. Her
medical history was notable for secondary biliary cirrhosis devel­
oped on primary sclerosing cholangitis. Physical examination re­
vealed abdominal tenderness, hepatomegaly, splenomegaly, and leg
Figure 1. Contrast-enhanced abdominal CT scanner. Coronal view demonstrating
liver shrinkage (2 arrows at top), the giant caudate lobe (asterisk), and evidence of
portal hypertension including splenomegaly (3 arrows at upper right) and mild as­
⁎ cites (single arrow at bottom). CT, computed tomography.
Corresponding author.
E-mail address: alexdehemptinne90@gmail.com (A. de Hemptinne).

https://doi.org/10.1016/j.gassur.2024.02.031
1091-255X/© 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.
A. de Hemptinne et al. Journal of Gastrointestinal Surgery 28 (2024) 1000–1002

Figure 2. Explanted native liver. Giant caudate lobe (asterisk) measured 15 cm in maximum diameter.

Figure 3. Liver volumetry: caudate lobe representing 79% of the total liver volume.

In this context of end-stage liver disease (Child-Pugh class C), the relevant: the caudate lobe representing here 79% of the total liver
patient underwent orthotopic liver transplantation with uneventful volume (Fig. 3) as opposed to the average of 2% to 3% [2].
postoperative course. Giant caudate lobe (15 cm in maximum dia­ Caudate lobe enlargement appears to be primarily explained by
meter) was found on the explanted native liver (Fig. 2), which is hemokinetic abnormalities. Hepatic fibrosis and compression of re­
common in patients with liver cirrhosis, especially those with sec­ generative nodules lead to a decrease in portal flow and hepatic vein
ondary biliary cirrhosis [1]. Histopathologic examination had shown drainage and, by this way, to overall liver shrinkage. Conversely, the
patent hepatic veins and micronodular cirrhosis. caudate lobe maintains an efficient and autonomous venous drai­
nage and also represents a shorter intrahepatic pathway for portal
blood. Therefore, this characteristic would explain the compensatory
Discussion hypertrophy of the unaffected caudate lobe, which contrasts the
atrophy observed in other hepatic segments [3].
In this case, cirrhosis developed on a background of primary However, as reported by Dodd et al. [1], there is a significant
sclerosing cholangitis. This chronic idiopathic inflammatory disease difference in hepatic morphology observed in patients with primary
of the bile ducts leads to multifocal strictures of the biliary tree that, sclerosing cholangitis-induced cirrhosis compared with those with
ultimately, result in secondary biliary cirrhosis. Given an exceeding end-stage cirrhosis of other causes. In secondary biliary cirrhosis
caudate lobe hypertrophy, the term “giant” appears entirely cases, hypertrophy of the caudate lobe is present in nearly all

1001
A. de Hemptinne et al. Journal of Gastrointestinal Surgery 28 (2024) 1000–1002

patients (98%), whereas in other types of cirrhosis, such as hyper­ provided radiologic data; and D. Azoulay coordinated the paper ela­
trophy, it is much less prevalent (36%). This variation seems to arise boration and revised the article.
from the observation that the bile ducts of the caudate lobe appear
to be unaffected or less affected in patients with primary sclerosing
cholangitis, resulting in compensatory hypertrophy. Declaration of competing interest

Ethics approval The authors declare no competing interests.

The authors are accountable for all aspects of the work in en­
suring that questions related to the accuracy or integrity of any part References
of the work are appropriately investigated and resolved. Written
informed consent was obtained from the patient for publication of [1] Dodd 3rd GD, Baron RL, Oliver 3rd JH, Federle MP. End-stage primary sclerosing
cholangitis: CT findings of hepatic morphology in 36 patients. Radiology
this GI Image. Board institutional approval was not required.
1999;211(2):357–62.
[2] Wang W, Zhang Z, Wang J. Subtotal (segment II-VIII) hepatectomy for bilateral
Author contributions diffuse hepatolithiasis with compensatory caudate lobe hypertrophy: a report of
two cases. BMC Gastroenterol 2020;20(1):350.
[3] Zhou XP, Lu T, Wei YG, Chen XZ. Liver volume variation in patients with
D. Azoulay and A. de Hemptinne performed the surgery; A. de virus-induced cirrhosis: findings on MDCT. AJR Am J Roentgenol
Hemptinne reviewed current literature and wrote the paper; T. Husson 2007;189(3):153–9.

1002