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Inflammatory Mass of the Mesentery: Diagnostic and Therapeutic Problems
Inflammatory Mass of the Mesentery: Diagnostic and Therapeutic Problems WILLIAM E. EVANS, M.D.* THOMAS R. WALL, M.D., F.A.C.S.** EDWIN H. ELLISON, M.D., F.A.C.S.***
Occasionally lesions are encountered intraoperatively which, because of their mode of presentation or their rarity, make positive identification difficult if not impossible. The following case illustrates some of the problems presented by such a lesion.
CASE REPORT
HISTORY AND PHYSICAL EXAMINATION. R. D., a 56 year old Caucasian man, was admitted on April14, 1965, for evaluation of abdominal pain of 72 hours' duration. When first noted, the pain was vague, constant, non-radiating, of moderate intensity, and localized generally to the epigastrium. Anorexia and nausea began within several hours. Symptoms persisted unchanged until the day of admission when the severity of pain increased markedly and localized in the right lower quadrant. No previous gastrointestinal symptoms could be elicited. Asymptomatic cholelithiasis had been demonstrated five years prior to admission. Blood pressure was 130/60 mm. Hg, pulse 86 per min., respirations 16 per min., and temperature 99.4°F. (orally). Pertinent findings were limited to the abdomen, which was slightly distended. Bowel sounds were normal. Guarding was present in the right lower quadrant and point tendemess and rebound were localized to the region of McBurney's point. Rectal tendemess was localized to the right lower quadrant. Hemoglobin was 15.2 gm. per 100 mi. hematocrit 45 per cent. White blood count was 10,500 per cu. mm. with 15 nonsegmented cells. Chest x-ray showed no abnormality. *Assistant Professor of Surgery, Marquette School of Medicine, Milwaukee, Wisconsin ''*Associate Professor of Surgery, Marquette School of Medicine, Milwaukee, Wisconsin '''*''Late Professor of Surgery, Marquette School of Medicine (died May 11, 1970)
Surgical Clinics of North America- Vol. 50, No. 5, October, 1970
1039
1040
WILLIAM
E.
EvANS, THOMAS
R.
WALL, EDWIN
H.
ELLISON
FIRST OPERATION. A diagnosis of acute appendicitis was made. At exploration the appendix was grossly normal. A mass 3 x 4 x 2 em. was identified in the mesentery at the angle of junction of the ileum and right colon. Edema was present and vascularity was slightly increased over the mass. The mass was firm and non-fluctuant. Numerous enlarged lymph nodes were noted in the mesentery. The colon and distal ileum were grossly normal, with no evidence of inflammation or edema of the bowel wall. The small bowel was slightly distended. Because of the obscure nature of the mass, and because the mass did not appear to involve the intestine but was localized to the mesentery, exploration was concluded. The postoperative course was marked by temperature elevation and abdominal distention. An abdominal series (Fig. lA) 6 days after operation showed a pattern of small bowel obstruction. Barium enema was normal except for several diverticula noted in the colon; barium refluxed into the ileum, which appeared slightly distended (Fig. lB). SECOND OPERATION. The patient was observed for 24 hours, and when signs and symptoms did not abate, exploration was carried out. Several areas of kinking, felt to be due to adhesive bands, were identifi.ed. The mass was again identified but was described as being smaller than originally noted. Lysis of adhesions was carried out, and a Cantor tube inserted and Levin suction continued. Four days later distention had resolved and the patient was passing flatus and liquid stools. The Cantor tube and Levin tube were clamped. Within 24 hours distention
Figure 1. A, Upright abdominal x-ray film shows small bowel distention and fluid levels. B, Barium enema shows diverticula of the colon. Reflux into the ileum is seen. A distended loop of small bowel is not~d just medial to the right colon.
INFLAMMATORY MASS OF THE MESENTERY
1041
recurred and vomiting began. X-ray examination showed intestinal distention again suggestive of small bowel obstruction (Fig. 2A). Barium inserted through the intestinal tube was noted to remain within the small intestine (Fig. 2B). Attempts to dislodge the tube were unsuccessful. A diagnosis of small bowel obstruction was made. The possibility of obstruction having resulted from kinking of the long tube was considered. The patient was seen by one of us (E.H.E.). White blood count was 15,050 per cu. mm. with 26 nonsegmented cells. Temperature was 99.2°F. Because of the history of small bowel obstruction and the presence of the mass in the mesentery of the distal ileum, consideration was given to regional enteritis as the underlying cause of bowel dysfunction. Additional history of ingestion of fish 3 days prior to the onset of symptoms raised the possibility of foreign body perforation of the ileum or cecum. THIRD OPERATION. At surgery there was marked distention of the small bowel. The mass was again noted. The small bowel and colon were grossly normal except for distention. The exact etiology of this mass was unclear, but it was felt to be related to the intestinal dysfunction. A right hemicolectomy with resection of approximately 10 inches of distal ileum was carried out. Resection included the mass within the mesentery. Intestinal continuity was re-established by end-to-end ileo transverse colostomy. Because of the marked intestinal distention a tube ileostomy was done in an attempt to decompress the area of anastomosis (Fig. 3).
Figure 2. A, Distended small bowel is again noted. B. Small bowel fluid levels are present. Barium inserted through the tube remains primarily in the small bowel.
1042
WILLIAM
E.
EVANS, THOMAS
R.
WALL, EDWIN
H.
ELLISON
Figure 3. A, Site of the diverticulum is noted. B, Anastomosis and decompression ileostomy is outlined.
The specimen was opened and a diverticulum of the ileum was identified which had perforated into the mesentery with resultant localized abscess formation. Distention slowly decreased over the first 4 days after operation; the patient began passing flatus, abdominal girth decreased from 38 to 34 inches, and oral fluids were started. Ileostomy drainage averaged approximately 1500 cc. per day. On the ninth postoperative day the patient noted increased flatus and had a bowel movement. Ileostomy drainage abruptly decreased to 150 cc. per 24 hours. Girth decreased during the ninth day from 34 to 24 inches. Recovery from this point was uneventful. Ileostomy and gastrostomy tubes were removed on the 17th postoperative day and the patient was discharged 4 days later.
COMMENT When Meckel's diverticula are excluded from consideration, diverticula of the small intestine are rarely encountered distal to the duodenum. Edwards, in reviewing over 4000 upper gastrointestinal barium series, found only four diverticula of the jejunoileum. When 881 autopsies were studied, five diverticula were found. 2 Further indication of the rarity of ileal diverticula is noted in the review of Benson, Dixon, and Waugh. 1 Of 122 cases of non-Meckel diverticula of the jejunoileum, 100 were in the jejunum, and 17 in the ileum, and five involved the entire small bowel. Associated colon diverticula were found in 44 per cent,! As contrasted to Meckel's diverticula, the wall of the diverticulum
INFLAMMATORY MASS OF THE MESENTERY
1043
consists of mucosa and submucosa which presumably herniate through areas of blood vessel penetration. Nearly all occur on the mesenteric border. 4 Perforation in the case presented occurred into the leaves of the mesentery. The bowel wall itself appeared grossly normal. Symptoms are said to occur in less than 50 per cent of patients known to harbor these diverticula, and have usually resulted from lowgrade bowel obstruction secondary to adhesions of the diverticulum to adjacent viscera, pressure from large diverticula harboring debris, hypertrophy of the diverticulum-containing segment, or diverticulitis. 3 Diverticulitis when it occurs results in symptoms so closely resembling other intra-abdominal inflammatory conditions that preoperative consideration is seldom given to this diagnosis. In the case presented symptomatology mimicked acute appendicitis. The exact nature of the pathology was never fully clarified until the specimen had been removed and opened, and the diverticulum identified. At the first operation the non-fluctant inflammatory mass of the mesentery that was encountered did not appear to involve the bowel wall. At the time of dissection of the specimen it was apparent that perforation had occurred at the distal tip of the diverticulum, well away from the intestinal wall. Bowel dysfunction continued despite attempts at long-tube decompression, and later, re-exploration with lysis of the adhesions. At the third operation an exact diagnosis was still impossible. It did appear that the bowel dysfunction was related to the inflammatory mass present in the mesentery, and for this reason resection was elected. Because of the marked distention of the bowel and the feeling that the ileocolic anastomosis might be in jeopardy, a decompressing ileostomy was done proximal to the anastomosis. During the first few postoperative days copious secretions were returned from the ileostomy tube. It is felt that placement of this tube may have provided the measure of protection necessary for subsequent healing of this tenuous anastomosis. In addition the presence of the ileostomy tube served as a vent after the reinstitution of oral feeding, providing several days of alimentation which otherwise might not have been possible. The ileostomy tube provided an indication of the function of the anastomosis: the ileostomy drainage markedly decreased just prior to the return of normal gastrointestinal function. This type of venting procedure, although infrequently required, should be considered when an anastomosis must be carried out in the face of marked intestinal distention.
REFERENCES 1. Benson, R. E., Dixon, C. F., and Waugh, J. M.: Non-Meckel diverticula of the jejunum and ileum. Ann. Surg. 118:377, 1943. 2. Edwards, H.: Congenital diverticula of the intestine. Brit. J. Surg., 17:7, 1929. 3. Localio, S. A., and Stahl, W. M.: Diverticular disease of the alimentary tract. Curr. Prob. Surg., January 1968. 4. Shackelford, R. T.: Bickham-Callander's Surgery of the Alimentary Tract, Vol. II. Philadelphia, W. B. Saunders. 1955. p. 1017.
Marquette School of Medicine 8700 West Wisconsin Avenue Milwaukee, Wisconsin 53226
Occasionally lesions are encountered intraoperatively which, because of their mode of presentation or their rarity, make positive identification difficult if not impossible. The following case illustrates some of the problems presented by such a lesion.
CASE REPORT
HISTORY AND PHYSICAL EXAMINATION. R. D., a 56 year old Caucasian man, was admitted on April14, 1965, for evaluation of abdominal pain of 72 hours' duration. When first noted, the pain was vague, constant, non-radiating, of moderate intensity, and localized generally to the epigastrium. Anorexia and nausea began within several hours. Symptoms persisted unchanged until the day of admission when the severity of pain increased markedly and localized in the right lower quadrant. No previous gastrointestinal symptoms could be elicited. Asymptomatic cholelithiasis had been demonstrated five years prior to admission. Blood pressure was 130/60 mm. Hg, pulse 86 per min., respirations 16 per min., and temperature 99.4°F. (orally). Pertinent findings were limited to the abdomen, which was slightly distended. Bowel sounds were normal. Guarding was present in the right lower quadrant and point tendemess and rebound were localized to the region of McBurney's point. Rectal tendemess was localized to the right lower quadrant. Hemoglobin was 15.2 gm. per 100 mi. hematocrit 45 per cent. White blood count was 10,500 per cu. mm. with 15 nonsegmented cells. Chest x-ray showed no abnormality. *Assistant Professor of Surgery, Marquette School of Medicine, Milwaukee, Wisconsin ''*Associate Professor of Surgery, Marquette School of Medicine, Milwaukee, Wisconsin '''*''Late Professor of Surgery, Marquette School of Medicine (died May 11, 1970)
Surgical Clinics of North America- Vol. 50, No. 5, October, 1970
1039
1040
WILLIAM
E.
EvANS, THOMAS
R.
WALL, EDWIN
H.
ELLISON
FIRST OPERATION. A diagnosis of acute appendicitis was made. At exploration the appendix was grossly normal. A mass 3 x 4 x 2 em. was identified in the mesentery at the angle of junction of the ileum and right colon. Edema was present and vascularity was slightly increased over the mass. The mass was firm and non-fluctuant. Numerous enlarged lymph nodes were noted in the mesentery. The colon and distal ileum were grossly normal, with no evidence of inflammation or edema of the bowel wall. The small bowel was slightly distended. Because of the obscure nature of the mass, and because the mass did not appear to involve the intestine but was localized to the mesentery, exploration was concluded. The postoperative course was marked by temperature elevation and abdominal distention. An abdominal series (Fig. lA) 6 days after operation showed a pattern of small bowel obstruction. Barium enema was normal except for several diverticula noted in the colon; barium refluxed into the ileum, which appeared slightly distended (Fig. lB). SECOND OPERATION. The patient was observed for 24 hours, and when signs and symptoms did not abate, exploration was carried out. Several areas of kinking, felt to be due to adhesive bands, were identifi.ed. The mass was again identified but was described as being smaller than originally noted. Lysis of adhesions was carried out, and a Cantor tube inserted and Levin suction continued. Four days later distention had resolved and the patient was passing flatus and liquid stools. The Cantor tube and Levin tube were clamped. Within 24 hours distention
Figure 1. A, Upright abdominal x-ray film shows small bowel distention and fluid levels. B, Barium enema shows diverticula of the colon. Reflux into the ileum is seen. A distended loop of small bowel is not~d just medial to the right colon.
INFLAMMATORY MASS OF THE MESENTERY
1041
recurred and vomiting began. X-ray examination showed intestinal distention again suggestive of small bowel obstruction (Fig. 2A). Barium inserted through the intestinal tube was noted to remain within the small intestine (Fig. 2B). Attempts to dislodge the tube were unsuccessful. A diagnosis of small bowel obstruction was made. The possibility of obstruction having resulted from kinking of the long tube was considered. The patient was seen by one of us (E.H.E.). White blood count was 15,050 per cu. mm. with 26 nonsegmented cells. Temperature was 99.2°F. Because of the history of small bowel obstruction and the presence of the mass in the mesentery of the distal ileum, consideration was given to regional enteritis as the underlying cause of bowel dysfunction. Additional history of ingestion of fish 3 days prior to the onset of symptoms raised the possibility of foreign body perforation of the ileum or cecum. THIRD OPERATION. At surgery there was marked distention of the small bowel. The mass was again noted. The small bowel and colon were grossly normal except for distention. The exact etiology of this mass was unclear, but it was felt to be related to the intestinal dysfunction. A right hemicolectomy with resection of approximately 10 inches of distal ileum was carried out. Resection included the mass within the mesentery. Intestinal continuity was re-established by end-to-end ileo transverse colostomy. Because of the marked intestinal distention a tube ileostomy was done in an attempt to decompress the area of anastomosis (Fig. 3).
Figure 2. A, Distended small bowel is again noted. B. Small bowel fluid levels are present. Barium inserted through the tube remains primarily in the small bowel.
1042
WILLIAM
E.
EVANS, THOMAS
R.
WALL, EDWIN
H.
ELLISON
Figure 3. A, Site of the diverticulum is noted. B, Anastomosis and decompression ileostomy is outlined.
The specimen was opened and a diverticulum of the ileum was identified which had perforated into the mesentery with resultant localized abscess formation. Distention slowly decreased over the first 4 days after operation; the patient began passing flatus, abdominal girth decreased from 38 to 34 inches, and oral fluids were started. Ileostomy drainage averaged approximately 1500 cc. per day. On the ninth postoperative day the patient noted increased flatus and had a bowel movement. Ileostomy drainage abruptly decreased to 150 cc. per 24 hours. Girth decreased during the ninth day from 34 to 24 inches. Recovery from this point was uneventful. Ileostomy and gastrostomy tubes were removed on the 17th postoperative day and the patient was discharged 4 days later.
COMMENT When Meckel's diverticula are excluded from consideration, diverticula of the small intestine are rarely encountered distal to the duodenum. Edwards, in reviewing over 4000 upper gastrointestinal barium series, found only four diverticula of the jejunoileum. When 881 autopsies were studied, five diverticula were found. 2 Further indication of the rarity of ileal diverticula is noted in the review of Benson, Dixon, and Waugh. 1 Of 122 cases of non-Meckel diverticula of the jejunoileum, 100 were in the jejunum, and 17 in the ileum, and five involved the entire small bowel. Associated colon diverticula were found in 44 per cent,! As contrasted to Meckel's diverticula, the wall of the diverticulum
INFLAMMATORY MASS OF THE MESENTERY
1043
consists of mucosa and submucosa which presumably herniate through areas of blood vessel penetration. Nearly all occur on the mesenteric border. 4 Perforation in the case presented occurred into the leaves of the mesentery. The bowel wall itself appeared grossly normal. Symptoms are said to occur in less than 50 per cent of patients known to harbor these diverticula, and have usually resulted from lowgrade bowel obstruction secondary to adhesions of the diverticulum to adjacent viscera, pressure from large diverticula harboring debris, hypertrophy of the diverticulum-containing segment, or diverticulitis. 3 Diverticulitis when it occurs results in symptoms so closely resembling other intra-abdominal inflammatory conditions that preoperative consideration is seldom given to this diagnosis. In the case presented symptomatology mimicked acute appendicitis. The exact nature of the pathology was never fully clarified until the specimen had been removed and opened, and the diverticulum identified. At the first operation the non-fluctant inflammatory mass of the mesentery that was encountered did not appear to involve the bowel wall. At the time of dissection of the specimen it was apparent that perforation had occurred at the distal tip of the diverticulum, well away from the intestinal wall. Bowel dysfunction continued despite attempts at long-tube decompression, and later, re-exploration with lysis of the adhesions. At the third operation an exact diagnosis was still impossible. It did appear that the bowel dysfunction was related to the inflammatory mass present in the mesentery, and for this reason resection was elected. Because of the marked distention of the bowel and the feeling that the ileocolic anastomosis might be in jeopardy, a decompressing ileostomy was done proximal to the anastomosis. During the first few postoperative days copious secretions were returned from the ileostomy tube. It is felt that placement of this tube may have provided the measure of protection necessary for subsequent healing of this tenuous anastomosis. In addition the presence of the ileostomy tube served as a vent after the reinstitution of oral feeding, providing several days of alimentation which otherwise might not have been possible. The ileostomy tube provided an indication of the function of the anastomosis: the ileostomy drainage markedly decreased just prior to the return of normal gastrointestinal function. This type of venting procedure, although infrequently required, should be considered when an anastomosis must be carried out in the face of marked intestinal distention.
REFERENCES 1. Benson, R. E., Dixon, C. F., and Waugh, J. M.: Non-Meckel diverticula of the jejunum and ileum. Ann. Surg. 118:377, 1943. 2. Edwards, H.: Congenital diverticula of the intestine. Brit. J. Surg., 17:7, 1929. 3. Localio, S. A., and Stahl, W. M.: Diverticular disease of the alimentary tract. Curr. Prob. Surg., January 1968. 4. Shackelford, R. T.: Bickham-Callander's Surgery of the Alimentary Tract, Vol. II. Philadelphia, W. B. Saunders. 1955. p. 1017.
Marquette School of Medicine 8700 West Wisconsin Avenue Milwaukee, Wisconsin 53226