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Abdominal Ultrasonography in a Mesenteric Cyst Presenting as Ascites
GASTROENTEROLOGY 69:761-764, 1975 Copyright© 1975 by The Williams & Wilkins Co.
Vol. 69, No. :1
Printed in U.S .A.
ABDOMINAL ULTRASONOGRAPHY IN A MESENTERIC CYST PRESENTING AS ASCITES MARVIN J. GORDON, MAJ., USAF, MC, ANn THOMAS E. SuMNEii, MAJ., USAF, MC
Division of Gastroenterology and Department of Radio/ofiiy, David Grant USAF M edical Center, Travis Air Force Base, California
A case of a mesenteric cyst presenting as the sudden onset of bloody ascites is reported. The diagnosis was suggested by abdominal ultrasonography. Mesenteric cysts are uncommon lesions, l-a often misdiagnosed prior to operation. The case presented here represents a previously unreported presentation, that of the sudden onset of bloody ascites. The diagnosis was suggested by abdominal ultrasonography which also has not been previously reported.
Case Report A 6-year-old male was admitted for abdominal swelling of 3 days' duration. The patient had an unremarkable birth and neonatal history, had undergone normal growth and development, and was in good health until 2 weeks prior to admission. At that time the patient complained of decreased appetite and postprandial abdominal discomfort. Three days prior to admission the patient and his parents noted tense abdominal swelling, although the patient noted no new symptoms and continued his usual activities. Physical examination revealed a pleasant alert 6-year-old, appearing slightly wasted but in no distress. Both hemidiaphragms were eval uated with decreased excursion. The abdomen was tensely distended with a palpable fluid wave but no shifting dullness. Bowel sounds were active. Laboratory tests revealed a hematocrit of 31% with microcytic indices; WBC 8600 cu mm with 47 % segmented, 41 % lymphs, 3 eosinophil, 9% monocyte, normal sedimentation rate, SGOT, albumin, globulin, and amylase. A ••mTc sulfur colloid liver-spleen scan was nor-
mal. Received March 24, 197 5. Accepted May 16, 1975 . Address requests for reprints to: Marvin ,J. Gordon, Major, USAF, MC, David Grant USAF Medical Center/SGHMCG, Travis AFB, California 94535. 761
Abdominal paracentesis in the midline between the umbilicus and symphysis pubis revealed a serosanguinous fluid . Analysis of the fluid revealed a hematocrit 5.4%, RBC 590,000 cu mm, WBC 4900 cu mm with 97% lymph, 3 % segmented, specific gravity 1.024, albumin 2.2 g per 100 ml total protein 3.6 g per 100 mllactate dehydrogenase 424 IU, amylase 53 Somogyi units. Smear was negative f(>r bacteria, acidfast organisms, and fungi. Bacterial cuit ure was negative. Plain abdominal roentgenograms showed a large, water density, noncalcified mass displacing bowel loops into the right upper quadrant (fig. 1). Intravenous urography demonstrated mild right hydronephrosis owing to ureteral compression at the pelvic brim. Superior and posterior extrinsic displacement of large bowel was shown by barium enema. Upper gastroin testinal series demonstrated midline elongation and effacement of ;:~. loop of jejunum plus displacement of the remainder of the small bowel into the right upper quadrant by the anterior abdominal mass (fig. 2, A and B). Sonography revealed an echo-free, smooth walled structure with good sound transmission shown by strong, multiple back wall echoes consistent with a cystic ultrasonic pattern. Midline linear echoes were recorded, which suggested that the mass was bilobed (fig. 2, C and D). It was felt that the midline linear echoes represented reflections from the elongated and effaced jejunal loop. On the 7th hospital day the patient underwent an abdominal exploration. A 30- by 15cm, 4000-g, thin walled bluish bilocular cystic mass was found adherent to and partially compressing a loop of jejunum (fig. 3). Gross examination revealed the two compartments to communicate with each other through a small opening but not to communicate with the jejunal loop. The cyst fluid was bloody and
762
CASE REPORTS
Vol. 69, No.3
FIG. 1. Supine (A) and lateral (B) abdominal roentgenograms show a large, noncalcified anterior mass with bowel draped over it.
FIG. 2. Supine (A) and lateral (B) upper gastrointestinal study reveal extrinsic effacement of a loop of jejunum plus displacement of small bowel into the right upper quadrant. C supine transverse (r, right; I, left; u, umbilicus) and D longitudinal (h, head; f, foot; u, umbilicus) sonogram demonstrates a large bilobed echo-free mass with good sound transmission shown by strong multiple back wall echoes typical of a cystic mass.
Septembf'r 1975
CASE REPORTS
FIG. 3. Gross specimen showing a bilobed 30- by 15-cm, 4000-g mesenteric cyst with the adherent loop of jejunum.
clots were found both floating free and adherent to the cyst wall. Microscopic examination revealed the wall to contain some muscle and dilated blood vessels and was lined by mesothelial-like flat cells. The final diagnosis was mesenteric cyst. The patient recovered, returned home, and has continued to do well over the ensuing months.
Discussion Mesenteric cysts are uncommon lesions which have various presenting signs and symptoms and are often misdiagnosed prior to surgery. The acute onset of abdominal pain, tenderness, and rebound may suggest acute appendicitis. 2 • •- 6 The acute onset of abdominal pain, fever, and an adnexal fullness may suggest pelvic peritonitis secondary to a perforated appendix 7 or a twisted or ruptured ovarian cyst. 7 Acute symptoms have also been misdiagnosed as Meckel's diverticulitis. 3 Intestinal obstruction secondary to the cyst'· 5 · 8 -•o or volvulus due to the cyst 9 may present with vomiting and abdominal distention. Rectal bleeding from engorgement of rectal vessels due to the cyst has also been reported as a presenting complaint. 1 The mass produced by a mesenteric cyst is also variable. It may be an asymptomatic mass found on physical examination and may be misdiagnosed as an ovarian cyst, 3 splenomegaly, 2 pelvic sarcoma, 2 or pancreatic pseudocyst. 11 It may be accompanied by chronic pain, suggesting an ovar-
763
ian cyst, 3 ovarian tumor, 4 or renal cyst. 12 Some mesenteric cysts are found incidentally at laparotomy. 2 • 5 Mesenteric cysts may be large enough to cause generalized abdominal distention•· '· 5 • 13 - 16 and may present as chronic abdominal distention. 15 · 16 The mass may appear acutely 8 • 17 or may rapidly enlarge. 1 • 9 ' 18 Rapid enlargement has been mistaken for an acutely enlarging abdominal aortic aneurysm. 18 The mass may herniate through the inguinal canal and be found during repair of a congenital inguinal hernia. 19 The wall of the cyst may show calcification. 2 • 5 A mesenteric cyst mimicking chronic recurrent chylous ascites has been reported. 13 No mesenteric cysts have been reported to present as the sudden onset of ascites. However, two omental cysts have been reported to present with sudden abdominal distention with a paracentesis done in one case. Both of these cysts were huge and revealed evidence of recent hemorrhage into the cyst. 5 Since evidence of hemorrhage into the cyst has also been seen in rapidly expanding mesenteric cysts, 8 • 17 • 18 hemorrhage may be the mechanism of rapid enlargement as seen in the case reported. Omental cysts, although differing little from mesenteric cysts except for location, should not entrap a loop of bowel as in the present case. The diagnosis of a mesenteric cyst is suggested by the findings on plain abdominal X-rays, upper and lower gastrointestinal series, intravenous pyelogram, 5 or arteriography. 15 ' 20 Various diagnostic potentials of abdominal ultrasound in the pediatric patient have been reported recently. 21 • 2 '1 However, combined B-mode and A-mode sonography in mesenteric cysts has not been cited. Its use in our patient supported the radiographic differentiation of ascites from a mass and diagnosed its cystic nature. Correlation of sonography with radiological and clinical findings suggested either a mesenteric cyst or small bowel duplication. Therefore, abdominal ultrasonography facilitated the preoperative evaluation and avoided further interventional procedures such as arteriography.
764
CASE
REPORTS
Addendum Since the original drafting of this manuscript, a case of abdominal ultrasonography of a mesenteric cyst has been published. 24 The authors also concluded that sonography facilitated preoperative evaluation. REFERENCES 1. Ford J: Mesenteric cysts review of the literature with report .of an unusual case. Am J Surg 99:878-884, 1960 2. Hardin W, Hardy J: Mesenteric cysts . Am J Surg 119:640-645, 1970 3. Steinreich 0: The diagnosis of mesenteric cysts. Ann Surg 142:889-894, 1955 4. Farrell W, Grube P: Intra-abdominal cystic lym· phangiomas . Am J Surg 108:790-793, 1964 5. Walker A, Putnam T: Omental mesenteric and retroperitoneal cysts; A clinical study of 33 new cases. Ann Surg 178:13-19, 1973 6. Martin W, Grotzinger P, Zaydon T: Chylous cyst of the mesentery. Ann Surg 140:132- 134, 1954 7 . Viar W, Scott W, Donald J: Mesenteric cavernous lymphangiomata; brief review and report of two cases. Ann Surg 153:157- 160, 1961 8. Fahmy A, Smith R, Garner M , et a!: Mesenteric cyst presenting as an acute surgical abdomen. Am Surg 32:654-656, 1966 9. Stahl W , Joy R: Chylous cysts of the mesentery in infants. J Pediatr 58:373-376, 1961 10. Fish J, Fair W, Canby J: Intestinal obstruction in the newborn an unusual case due to mesenteric cyst. Arch Surg 90:317-318, 1965 11. Sturim H, Kouchoukos N: Intra-abdominal cystic lymphangioma presenting as a pancreatic pseudocyst. Am J Surg 109:807-809, 1965 12 . Barr W, Yamashita T: Mesenteric cysts review of the literature and report of a case. Am J Gastroenterol 41:53-57, 1964
Vol. 69, No. :J
13. Whittlesey R, Guenther H, Huntley W: Mesen. teric cysts and chylous ascites. Arch Pediat 77:357-363, 1960 14. Castleman B, Kibbee B : Case records of the Massachusetts General Hospital Case 43-1961. N Eng! J Med 264:1262- 1265, 1961 15. Potter B, McSweeney W: Sigmoid mesenteric cyst angiographic findings. Radiology 106:285-286, 1973 16. Arnheim E, Schneck H, Normal A, et a!: Mesen· teric cysts in infancy and childhood. Review of the literature and report of a case. Pediatrics 24:469-476, 1959 17. Hardin W, Elliott R, Wesson R, et al: Hemor· rhagic mesenteric cyst simulating an acute ahdomen. Am Surg 33:733-736, 1967 18. Stolley P, Buxbaum R, VanWormer D: A mesen· teric cyst simulating an aortic aneurysm. Am ,J Dig Dis 9:538-542, 1964 19. Hoffman E: Multicystic retroperitoneallymphan· giomata presenting as an indirect inguinal hernia in a newborn. Am Surg 31:525-531, 1965 20. Gordon R, Capetillo A, Principato D: Angiographic demonstration of a lymphatic cyst of the mesentery . Am J Roentgenol Radium Ther Nucl Med 104:870-873, 1968 21. Walls W, Roberts F, Templeton A: B-Scan diag. nostic ultrasound in the pediatric patient. Am ,J Roentgenol Radium Ther Nucl Med 120:431-4:l7. 1974 22. Rose J , Becker J, Staiano S, et al: B-mode sonography of abdominal masses. Am J Roent· genol Radium Ther Nucl Med 120:691-698, 1974 23. Goldberg BB, Capitanio MA, Kirkpatrick JA: Ultrasonic evaluation of masses in pediatric pa· tients. Am J Roentgenol Radium Ther Nucl Med 116:677- 684, 1972 24. Sanders RC: B-scan ultrasound in the manage· ment of abdominal masses in children .•JAMA 231:81-83, 1975.
Vol. 69, No. :1
Printed in U.S .A.
ABDOMINAL ULTRASONOGRAPHY IN A MESENTERIC CYST PRESENTING AS ASCITES MARVIN J. GORDON, MAJ., USAF, MC, ANn THOMAS E. SuMNEii, MAJ., USAF, MC
Division of Gastroenterology and Department of Radio/ofiiy, David Grant USAF M edical Center, Travis Air Force Base, California
A case of a mesenteric cyst presenting as the sudden onset of bloody ascites is reported. The diagnosis was suggested by abdominal ultrasonography. Mesenteric cysts are uncommon lesions, l-a often misdiagnosed prior to operation. The case presented here represents a previously unreported presentation, that of the sudden onset of bloody ascites. The diagnosis was suggested by abdominal ultrasonography which also has not been previously reported.
Case Report A 6-year-old male was admitted for abdominal swelling of 3 days' duration. The patient had an unremarkable birth and neonatal history, had undergone normal growth and development, and was in good health until 2 weeks prior to admission. At that time the patient complained of decreased appetite and postprandial abdominal discomfort. Three days prior to admission the patient and his parents noted tense abdominal swelling, although the patient noted no new symptoms and continued his usual activities. Physical examination revealed a pleasant alert 6-year-old, appearing slightly wasted but in no distress. Both hemidiaphragms were eval uated with decreased excursion. The abdomen was tensely distended with a palpable fluid wave but no shifting dullness. Bowel sounds were active. Laboratory tests revealed a hematocrit of 31% with microcytic indices; WBC 8600 cu mm with 47 % segmented, 41 % lymphs, 3 eosinophil, 9% monocyte, normal sedimentation rate, SGOT, albumin, globulin, and amylase. A ••mTc sulfur colloid liver-spleen scan was nor-
mal. Received March 24, 197 5. Accepted May 16, 1975 . Address requests for reprints to: Marvin ,J. Gordon, Major, USAF, MC, David Grant USAF Medical Center/SGHMCG, Travis AFB, California 94535. 761
Abdominal paracentesis in the midline between the umbilicus and symphysis pubis revealed a serosanguinous fluid . Analysis of the fluid revealed a hematocrit 5.4%, RBC 590,000 cu mm, WBC 4900 cu mm with 97% lymph, 3 % segmented, specific gravity 1.024, albumin 2.2 g per 100 ml total protein 3.6 g per 100 mllactate dehydrogenase 424 IU, amylase 53 Somogyi units. Smear was negative f(>r bacteria, acidfast organisms, and fungi. Bacterial cuit ure was negative. Plain abdominal roentgenograms showed a large, water density, noncalcified mass displacing bowel loops into the right upper quadrant (fig. 1). Intravenous urography demonstrated mild right hydronephrosis owing to ureteral compression at the pelvic brim. Superior and posterior extrinsic displacement of large bowel was shown by barium enema. Upper gastroin testinal series demonstrated midline elongation and effacement of ;:~. loop of jejunum plus displacement of the remainder of the small bowel into the right upper quadrant by the anterior abdominal mass (fig. 2, A and B). Sonography revealed an echo-free, smooth walled structure with good sound transmission shown by strong, multiple back wall echoes consistent with a cystic ultrasonic pattern. Midline linear echoes were recorded, which suggested that the mass was bilobed (fig. 2, C and D). It was felt that the midline linear echoes represented reflections from the elongated and effaced jejunal loop. On the 7th hospital day the patient underwent an abdominal exploration. A 30- by 15cm, 4000-g, thin walled bluish bilocular cystic mass was found adherent to and partially compressing a loop of jejunum (fig. 3). Gross examination revealed the two compartments to communicate with each other through a small opening but not to communicate with the jejunal loop. The cyst fluid was bloody and
762
CASE REPORTS
Vol. 69, No.3
FIG. 1. Supine (A) and lateral (B) abdominal roentgenograms show a large, noncalcified anterior mass with bowel draped over it.
FIG. 2. Supine (A) and lateral (B) upper gastrointestinal study reveal extrinsic effacement of a loop of jejunum plus displacement of small bowel into the right upper quadrant. C supine transverse (r, right; I, left; u, umbilicus) and D longitudinal (h, head; f, foot; u, umbilicus) sonogram demonstrates a large bilobed echo-free mass with good sound transmission shown by strong multiple back wall echoes typical of a cystic mass.
Septembf'r 1975
CASE REPORTS
FIG. 3. Gross specimen showing a bilobed 30- by 15-cm, 4000-g mesenteric cyst with the adherent loop of jejunum.
clots were found both floating free and adherent to the cyst wall. Microscopic examination revealed the wall to contain some muscle and dilated blood vessels and was lined by mesothelial-like flat cells. The final diagnosis was mesenteric cyst. The patient recovered, returned home, and has continued to do well over the ensuing months.
Discussion Mesenteric cysts are uncommon lesions which have various presenting signs and symptoms and are often misdiagnosed prior to surgery. The acute onset of abdominal pain, tenderness, and rebound may suggest acute appendicitis. 2 • •- 6 The acute onset of abdominal pain, fever, and an adnexal fullness may suggest pelvic peritonitis secondary to a perforated appendix 7 or a twisted or ruptured ovarian cyst. 7 Acute symptoms have also been misdiagnosed as Meckel's diverticulitis. 3 Intestinal obstruction secondary to the cyst'· 5 · 8 -•o or volvulus due to the cyst 9 may present with vomiting and abdominal distention. Rectal bleeding from engorgement of rectal vessels due to the cyst has also been reported as a presenting complaint. 1 The mass produced by a mesenteric cyst is also variable. It may be an asymptomatic mass found on physical examination and may be misdiagnosed as an ovarian cyst, 3 splenomegaly, 2 pelvic sarcoma, 2 or pancreatic pseudocyst. 11 It may be accompanied by chronic pain, suggesting an ovar-
763
ian cyst, 3 ovarian tumor, 4 or renal cyst. 12 Some mesenteric cysts are found incidentally at laparotomy. 2 • 5 Mesenteric cysts may be large enough to cause generalized abdominal distention•· '· 5 • 13 - 16 and may present as chronic abdominal distention. 15 · 16 The mass may appear acutely 8 • 17 or may rapidly enlarge. 1 • 9 ' 18 Rapid enlargement has been mistaken for an acutely enlarging abdominal aortic aneurysm. 18 The mass may herniate through the inguinal canal and be found during repair of a congenital inguinal hernia. 19 The wall of the cyst may show calcification. 2 • 5 A mesenteric cyst mimicking chronic recurrent chylous ascites has been reported. 13 No mesenteric cysts have been reported to present as the sudden onset of ascites. However, two omental cysts have been reported to present with sudden abdominal distention with a paracentesis done in one case. Both of these cysts were huge and revealed evidence of recent hemorrhage into the cyst. 5 Since evidence of hemorrhage into the cyst has also been seen in rapidly expanding mesenteric cysts, 8 • 17 • 18 hemorrhage may be the mechanism of rapid enlargement as seen in the case reported. Omental cysts, although differing little from mesenteric cysts except for location, should not entrap a loop of bowel as in the present case. The diagnosis of a mesenteric cyst is suggested by the findings on plain abdominal X-rays, upper and lower gastrointestinal series, intravenous pyelogram, 5 or arteriography. 15 ' 20 Various diagnostic potentials of abdominal ultrasound in the pediatric patient have been reported recently. 21 • 2 '1 However, combined B-mode and A-mode sonography in mesenteric cysts has not been cited. Its use in our patient supported the radiographic differentiation of ascites from a mass and diagnosed its cystic nature. Correlation of sonography with radiological and clinical findings suggested either a mesenteric cyst or small bowel duplication. Therefore, abdominal ultrasonography facilitated the preoperative evaluation and avoided further interventional procedures such as arteriography.
764
CASE
REPORTS
Addendum Since the original drafting of this manuscript, a case of abdominal ultrasonography of a mesenteric cyst has been published. 24 The authors also concluded that sonography facilitated preoperative evaluation. REFERENCES 1. Ford J: Mesenteric cysts review of the literature with report .of an unusual case. Am J Surg 99:878-884, 1960 2. Hardin W, Hardy J: Mesenteric cysts . Am J Surg 119:640-645, 1970 3. Steinreich 0: The diagnosis of mesenteric cysts. Ann Surg 142:889-894, 1955 4. Farrell W, Grube P: Intra-abdominal cystic lym· phangiomas . Am J Surg 108:790-793, 1964 5. Walker A, Putnam T: Omental mesenteric and retroperitoneal cysts; A clinical study of 33 new cases. Ann Surg 178:13-19, 1973 6. Martin W, Grotzinger P, Zaydon T: Chylous cyst of the mesentery. Ann Surg 140:132- 134, 1954 7 . Viar W, Scott W, Donald J: Mesenteric cavernous lymphangiomata; brief review and report of two cases. Ann Surg 153:157- 160, 1961 8. Fahmy A, Smith R, Garner M , et a!: Mesenteric cyst presenting as an acute surgical abdomen. Am Surg 32:654-656, 1966 9. Stahl W , Joy R: Chylous cysts of the mesentery in infants. J Pediatr 58:373-376, 1961 10. Fish J, Fair W, Canby J: Intestinal obstruction in the newborn an unusual case due to mesenteric cyst. Arch Surg 90:317-318, 1965 11. Sturim H, Kouchoukos N: Intra-abdominal cystic lymphangioma presenting as a pancreatic pseudocyst. Am J Surg 109:807-809, 1965 12 . Barr W, Yamashita T: Mesenteric cysts review of the literature and report of a case. Am J Gastroenterol 41:53-57, 1964
Vol. 69, No. :J
13. Whittlesey R, Guenther H, Huntley W: Mesen. teric cysts and chylous ascites. Arch Pediat 77:357-363, 1960 14. Castleman B, Kibbee B : Case records of the Massachusetts General Hospital Case 43-1961. N Eng! J Med 264:1262- 1265, 1961 15. Potter B, McSweeney W: Sigmoid mesenteric cyst angiographic findings. Radiology 106:285-286, 1973 16. Arnheim E, Schneck H, Normal A, et a!: Mesen· teric cysts in infancy and childhood. Review of the literature and report of a case. Pediatrics 24:469-476, 1959 17. Hardin W, Elliott R, Wesson R, et al: Hemor· rhagic mesenteric cyst simulating an acute ahdomen. Am Surg 33:733-736, 1967 18. Stolley P, Buxbaum R, VanWormer D: A mesen· teric cyst simulating an aortic aneurysm. Am ,J Dig Dis 9:538-542, 1964 19. Hoffman E: Multicystic retroperitoneallymphan· giomata presenting as an indirect inguinal hernia in a newborn. Am Surg 31:525-531, 1965 20. Gordon R, Capetillo A, Principato D: Angiographic demonstration of a lymphatic cyst of the mesentery . Am J Roentgenol Radium Ther Nucl Med 104:870-873, 1968 21. Walls W, Roberts F, Templeton A: B-Scan diag. nostic ultrasound in the pediatric patient. Am ,J Roentgenol Radium Ther Nucl Med 120:431-4:l7. 1974 22. Rose J , Becker J, Staiano S, et al: B-mode sonography of abdominal masses. Am J Roent· genol Radium Ther Nucl Med 120:691-698, 1974 23. Goldberg BB, Capitanio MA, Kirkpatrick JA: Ultrasonic evaluation of masses in pediatric pa· tients. Am J Roentgenol Radium Ther Nucl Med 116:677- 684, 1972 24. Sanders RC: B-scan ultrasound in the manage· ment of abdominal masses in children .•JAMA 231:81-83, 1975.