- Email: [email protected]
Case report: Volvulus of a mesenteric cyst—An unusual complication diagnosed by CT
Clinical Radiology (1992) 46, 211 212
Case Report: Volvulus of a Mesenteric Cyst-An Unusual Complication Diagnosed by CT J. N A M A S I V A Y A M , M. A. Z I E R V O G E L and A. S. H O L L M A N
Department of Radiology, Royal Hospitalfor Sick Children, Yorkhill, Glasgow A 10-year-old girl presented with colicky abdominal pain and a vague left sided mass on physical examination. Plain radiographs of the abdomen were unremarkable but ultrasound examination demonstrated a large right sided unilocular cystic abdominal mass. Computed tomographic features were diagnostic of volvulus of the proximal small bowel with associated mesenteric cyst. Surgery confirmed CT findings and no mid gut malrotation was noted at operation. Namasivayam, J., Ziervogel, M.A. & Hollman, A.S. (1992). Clinical Radiology 46, 211 212. Case Report: Volvulus of a Mesenteric Cyst An Unusual Complication Diagnosed by CT
Mesenteric cysts are uncommon and their pathological aetiology includes lymphangioma, pseudocyst, enteric cyst, enteric duplication cyst, mesothelial cyst and teratoma [1,2]. Although associated serious complications are rare with these lesions [3], obstruction and gangrene of the bowel with perforation has been reported [4]. We report a further unusual complication of a mesenteric cyst presenting with a volvulus of the jejunum. This was diagnosed by CT prior to surgery. This presentation has not been described previously to our knowledge.
on admission and just before the CT examination were unremarkable. Ultrasound revealed a large unilocular cystic mass with some fluid movement within it. The cyst extended from the upper abdomen to the pelvis, displacing the bladder inferiorly (Fig. 1). Occasional peristaltic waves were also observed in the cyst which raised the suspicion of the
CASE R E P O R T A 10-year-old girl was admitted with a 3 day history of colicky abdominal pain and persistent vomiting. A similar episode had occurred in the past. Clinical examination on this occasion indicated slight tenderness with a vague mass palpable in the left lower quadrant of the abdomen. The radiographic examinations of the abdomen carried out
(a)
(b) Fig. 1-Sagittal ultrasound examination of the pelvis shows the lower limit Of the unilocular cystic mass (arrow) with inferior displacement of the bladder. Correspondence to: Dr J. Namasivayam, Department of Radiology, Whipps Cross Hospital, Whipps Cross Road, London El 1 1NR.
Fig. 2 (a) CT examination of the upper abdomen shows the proximal jejunum spiralling around the mesenteric vessels (arrows), indicating volvulus of the bowel. The upper limit o f the cyst is also seen (arrowhead). (b) An image taken immediately below this level shows the cyst to have its origin from the jejunum (arrows). The features of volvulus are also seen.
212
CLINICAL RADIOLOGY
cyst being of bowel origin. Dynamic contrast enhanced CT showed the proximal jejunum to spiral around the mesenteric vessels, indicating volvulus of the bowel (Fig. 2a). Below this level, the cyst was noted to have its origin from the jejunum (Fig. 2b). Surgery confirmed the CT findings. A large thin walled cyst (8 x 7 × 6 cm) was found related to the proximaljejunum with a 720° volvulus of the jejunum. The affected part of the jejunum was viable following derotation. There was no evidence of intestinal malrotation. The cyst was excised and post-operative recovery was uneventful. The histologyshowed endothelial lining within the unilocular cyst and the features were typical of a benign lymphangiomatous mesenteric cyst. DISCUSSION T h e clinical p r e s e n t a t i o n o f mesenteric cyst is usually a t t r i b u t e d to the size, l o c a t i o n a n d c o m p l i c a t i o n s such as torsion, h a e m o r r h a g e , infection o r r u p t u r e o f these cysts [5], M e s e n t e r i c cysts tend to occur in children a n d y o u n g a d u l t s a n d . a r e m o r e c o m m o n i n f e m a l e s [2,3]. I t is u n c e r t a i n w h e t h e r these cysts are c o n g e n i t a l o r acquired. A b d o m i n a l p a i n is the c o m m o n e s t s y m p t o m e n c o u n t e r e d a n d has been r e p o r t e d in 80% o f p a t i e n t s with mesenteric cysts [6]. A l t h o u g h i n t e r m i t t e n t colicky p a i n is u s u a l l y t h o u g h t to be a result o f p a r t i a l o b s t r u c t i o n o f the bowel, in this case we present the colicky p a i n w i t h o u t b o w e l obstruction-suggested probable intermittent bowel i s c h a e m i a as a result o f volvulus. N a u s e a a n d v o m i t i n g are o t h e r a c c o m p a n y i n g s y m p t o m s . In spite o f the large size o f m o s t mesenteric cysts, m a n y are n o t p a l p a b l e because the cysts are flaccid a n d m o b i l e [5]. T h e r a d i o g r a p h o f the a b d o m e n is s e l d o m d i a g n o s t i c a l t h o u g h evidence o f a soft tissue m a s s a n d d i s p l a c e m e n t o f the b o w e l have been frequently o b s e r v e d in large review studies [2]. U l t r a s o n o g r a p h y has been described as an effective m e t h o d o f e v a l u a t i n g mesenteric cysts [7]. In o u r case this was so, b u t the c o m p l i c a t i o n b y volvulus was only d i a g n o s e d by C T e x a m i n a t i o n . T h e s o n o g r a p h i c a n d C T findings have been s h o w n to correlate well with the gross multicystic n a t u r e o f l y m p h a n g i o m a s [2]. H o w e v e r , in o u r p a t i e n t the cyst was u n i l o c u l a r with a thin wall as h a d been s h o w n on C T a n d u l t r a s o u n d .
Volvulus o f the m i d gut in children is m o s t c o m m o n l y due to integtinal m a l r o t a t i o n a n d C T a p p e a r a n c e s o f small bowel volvulus encircling the s u p e r i o r mesenteric vessels with a whirl-like p a t t e r n has been d e s c r i b e d [8,9]. In o u r case the volvulus w a s due to a large mesenteric cyst w i t h o u t m i d gut m a l r o t a t i o n . In s u m m a r y , u n e x p l a i n e d a b d o m i n a l p a i n in a child, w i t h o u t a n y specific localizing p h y s i c a l signs a n d unrem a r k a b l e r a d i o g r a p h i c findings w a r r a n t s an u r g e n t ultras o u n d e x a m i n a t i o n to refute o r c o n f i r m a b d o m i n a l p a t h o l o g y . I f a cystic a b d o m i n a l m a s s is d e t e c t e d on u l t r a s o u n d , a C T e x a m i n a t i o n m a y be useful in d e t e r m i n ing the exact origin o f the m a s s a n d in d i a g n o s i n g associated c o m p l i c a t i o n s such as volvulus.
REFERENCES
1 Prieto ML, Casanova A, Delgado J, Zabalza R. Cystic teratoma of the mesentery. Paediatric Radiology 1989;19:439. 2 Ros PR, Olmsted WW, Moser RP, Dachman AH, Hjermstad BH, Sobin LH. Mesenteric and omental cysts: histologic classification with imaging correlation. Radiology 1987;164:327-332. 3 Walker AR, Putnam TC. Omental, mesenteric and retroperitoneal cysts: a clinical study of 33 new cases. Annals of Surgery 1973;178: 13-19. 4 Kovalivker M, Motovic A. Obstruction and gangrene of bowel with perforation due to a mesenteric cyst in a newborn. Journal of Paediatric Surgery 1987;22(4):277-356. 5 Geer LL, Mittelstaedt CA, Staab EV, Gaisie G. Mesenteric cyst: sonographic appearance with CT correlation. Paediatric Radiology 1984;14:102-104. 6 Wood GS, Skandalakis JE. Embryologyfor surgeons. Philadelphia: WB Saunders. 70livencia-Yurvati AH, Leii~eit SH, Peterson DM. Bowel obstruction secondary to mesenteric cyst formation. Journal of American Osteopathic Association 1989;89(3):355-356. 8 Fisher JK. Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981;140:145. 9 Mori H, Hayashi K, Futagawa S, Utetani M, Yanagi T, Kurosaki N. Vascular compromise in chronic volvulus with mid gut malrotation. Paediatric Radiology 1987;17:277-281.
Case Report: Volvulus of a Mesenteric Cyst-An Unusual Complication Diagnosed by CT J. N A M A S I V A Y A M , M. A. Z I E R V O G E L and A. S. H O L L M A N
Department of Radiology, Royal Hospitalfor Sick Children, Yorkhill, Glasgow A 10-year-old girl presented with colicky abdominal pain and a vague left sided mass on physical examination. Plain radiographs of the abdomen were unremarkable but ultrasound examination demonstrated a large right sided unilocular cystic abdominal mass. Computed tomographic features were diagnostic of volvulus of the proximal small bowel with associated mesenteric cyst. Surgery confirmed CT findings and no mid gut malrotation was noted at operation. Namasivayam, J., Ziervogel, M.A. & Hollman, A.S. (1992). Clinical Radiology 46, 211 212. Case Report: Volvulus of a Mesenteric Cyst An Unusual Complication Diagnosed by CT
Mesenteric cysts are uncommon and their pathological aetiology includes lymphangioma, pseudocyst, enteric cyst, enteric duplication cyst, mesothelial cyst and teratoma [1,2]. Although associated serious complications are rare with these lesions [3], obstruction and gangrene of the bowel with perforation has been reported [4]. We report a further unusual complication of a mesenteric cyst presenting with a volvulus of the jejunum. This was diagnosed by CT prior to surgery. This presentation has not been described previously to our knowledge.
on admission and just before the CT examination were unremarkable. Ultrasound revealed a large unilocular cystic mass with some fluid movement within it. The cyst extended from the upper abdomen to the pelvis, displacing the bladder inferiorly (Fig. 1). Occasional peristaltic waves were also observed in the cyst which raised the suspicion of the
CASE R E P O R T A 10-year-old girl was admitted with a 3 day history of colicky abdominal pain and persistent vomiting. A similar episode had occurred in the past. Clinical examination on this occasion indicated slight tenderness with a vague mass palpable in the left lower quadrant of the abdomen. The radiographic examinations of the abdomen carried out
(a)
(b) Fig. 1-Sagittal ultrasound examination of the pelvis shows the lower limit Of the unilocular cystic mass (arrow) with inferior displacement of the bladder. Correspondence to: Dr J. Namasivayam, Department of Radiology, Whipps Cross Hospital, Whipps Cross Road, London El 1 1NR.
Fig. 2 (a) CT examination of the upper abdomen shows the proximal jejunum spiralling around the mesenteric vessels (arrows), indicating volvulus of the bowel. The upper limit o f the cyst is also seen (arrowhead). (b) An image taken immediately below this level shows the cyst to have its origin from the jejunum (arrows). The features of volvulus are also seen.
212
CLINICAL RADIOLOGY
cyst being of bowel origin. Dynamic contrast enhanced CT showed the proximal jejunum to spiral around the mesenteric vessels, indicating volvulus of the bowel (Fig. 2a). Below this level, the cyst was noted to have its origin from the jejunum (Fig. 2b). Surgery confirmed the CT findings. A large thin walled cyst (8 x 7 × 6 cm) was found related to the proximaljejunum with a 720° volvulus of the jejunum. The affected part of the jejunum was viable following derotation. There was no evidence of intestinal malrotation. The cyst was excised and post-operative recovery was uneventful. The histologyshowed endothelial lining within the unilocular cyst and the features were typical of a benign lymphangiomatous mesenteric cyst. DISCUSSION T h e clinical p r e s e n t a t i o n o f mesenteric cyst is usually a t t r i b u t e d to the size, l o c a t i o n a n d c o m p l i c a t i o n s such as torsion, h a e m o r r h a g e , infection o r r u p t u r e o f these cysts [5], M e s e n t e r i c cysts tend to occur in children a n d y o u n g a d u l t s a n d . a r e m o r e c o m m o n i n f e m a l e s [2,3]. I t is u n c e r t a i n w h e t h e r these cysts are c o n g e n i t a l o r acquired. A b d o m i n a l p a i n is the c o m m o n e s t s y m p t o m e n c o u n t e r e d a n d has been r e p o r t e d in 80% o f p a t i e n t s with mesenteric cysts [6]. A l t h o u g h i n t e r m i t t e n t colicky p a i n is u s u a l l y t h o u g h t to be a result o f p a r t i a l o b s t r u c t i o n o f the bowel, in this case we present the colicky p a i n w i t h o u t b o w e l obstruction-suggested probable intermittent bowel i s c h a e m i a as a result o f volvulus. N a u s e a a n d v o m i t i n g are o t h e r a c c o m p a n y i n g s y m p t o m s . In spite o f the large size o f m o s t mesenteric cysts, m a n y are n o t p a l p a b l e because the cysts are flaccid a n d m o b i l e [5]. T h e r a d i o g r a p h o f the a b d o m e n is s e l d o m d i a g n o s t i c a l t h o u g h evidence o f a soft tissue m a s s a n d d i s p l a c e m e n t o f the b o w e l have been frequently o b s e r v e d in large review studies [2]. U l t r a s o n o g r a p h y has been described as an effective m e t h o d o f e v a l u a t i n g mesenteric cysts [7]. In o u r case this was so, b u t the c o m p l i c a t i o n b y volvulus was only d i a g n o s e d by C T e x a m i n a t i o n . T h e s o n o g r a p h i c a n d C T findings have been s h o w n to correlate well with the gross multicystic n a t u r e o f l y m p h a n g i o m a s [2]. H o w e v e r , in o u r p a t i e n t the cyst was u n i l o c u l a r with a thin wall as h a d been s h o w n on C T a n d u l t r a s o u n d .
Volvulus o f the m i d gut in children is m o s t c o m m o n l y due to integtinal m a l r o t a t i o n a n d C T a p p e a r a n c e s o f small bowel volvulus encircling the s u p e r i o r mesenteric vessels with a whirl-like p a t t e r n has been d e s c r i b e d [8,9]. In o u r case the volvulus w a s due to a large mesenteric cyst w i t h o u t m i d gut m a l r o t a t i o n . In s u m m a r y , u n e x p l a i n e d a b d o m i n a l p a i n in a child, w i t h o u t a n y specific localizing p h y s i c a l signs a n d unrem a r k a b l e r a d i o g r a p h i c findings w a r r a n t s an u r g e n t ultras o u n d e x a m i n a t i o n to refute o r c o n f i r m a b d o m i n a l p a t h o l o g y . I f a cystic a b d o m i n a l m a s s is d e t e c t e d on u l t r a s o u n d , a C T e x a m i n a t i o n m a y be useful in d e t e r m i n ing the exact origin o f the m a s s a n d in d i a g n o s i n g associated c o m p l i c a t i o n s such as volvulus.
REFERENCES
1 Prieto ML, Casanova A, Delgado J, Zabalza R. Cystic teratoma of the mesentery. Paediatric Radiology 1989;19:439. 2 Ros PR, Olmsted WW, Moser RP, Dachman AH, Hjermstad BH, Sobin LH. Mesenteric and omental cysts: histologic classification with imaging correlation. Radiology 1987;164:327-332. 3 Walker AR, Putnam TC. Omental, mesenteric and retroperitoneal cysts: a clinical study of 33 new cases. Annals of Surgery 1973;178: 13-19. 4 Kovalivker M, Motovic A. Obstruction and gangrene of bowel with perforation due to a mesenteric cyst in a newborn. Journal of Paediatric Surgery 1987;22(4):277-356. 5 Geer LL, Mittelstaedt CA, Staab EV, Gaisie G. Mesenteric cyst: sonographic appearance with CT correlation. Paediatric Radiology 1984;14:102-104. 6 Wood GS, Skandalakis JE. Embryologyfor surgeons. Philadelphia: WB Saunders. 70livencia-Yurvati AH, Leii~eit SH, Peterson DM. Bowel obstruction secondary to mesenteric cyst formation. Journal of American Osteopathic Association 1989;89(3):355-356. 8 Fisher JK. Computed tomographic diagnosis of volvulus in intestinal malrotation. Radiology 1981;140:145. 9 Mori H, Hayashi K, Futagawa S, Utetani M, Yanagi T, Kurosaki N. Vascular compromise in chronic volvulus with mid gut malrotation. Paediatric Radiology 1987;17:277-281.