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“Rolling Ball” in the Abdomen
Electronic Clinical Challenges and Images in GI “Rolling Ball” in the Abdomen
Question: A 34-year-old woman presented with abdominal fullness and loss of appetite for ⬎5 months. She came to our department of surgery with the complaint of an intra-abdominal rolling mass. She had the sensation of something tumbling to the dependent portion of her abdomen when she changed position in bed. She had no history of pancreatitis or abdominal trauma. A movable, elastic mass with a smooth surface was palpated in the upper abdomen. Abdominal ultrasonography revealed a cystic mass lesion in the upper abdomen. Abdominal computed tomography (CT) scan showed a cystic mass with a thin cystic wall (Figure A). The cystic tumor had no communication with bowel or any retroperitoneal organ, such as pancreas or adrenal gland. Laparoscopy revealed an intra-mesenteric cystic tumor (Figure B), which was resected laparoscopically. The patient’s postoperative recovery was uneventful, and she remains in good health ⬎1 year postoperatively. What is the diagnosis?
See the GASTROENTEROLOGY web site (www.gastrojournal. org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. HUNG–HUA LIANG PO–LI WEI MING–TE HUANG Division of General Surgery Department of Surgery Taipei Medical University Hospital and Department of Surgery School of Medicine College of Medicine Taipei Medical University Conflicts of interest The authors disclose no conflicts. © 2011 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2010.03.060
GASTROENTEROLOGY 2011;140:e9 – e10
e10
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 140, No. 3
Answer to the Clinical Challenges and Images in GI Question: Image 5: Mesenteric Cyst in Mesenterium of Proximal Jejunum Grossly, the tumor was a mesenteric cyst with a smooth inner and outer surface. No obvious hemorrhage or necrosis was noted. Microscopic examination demonstrated a cavitary lesion walled by fibromuscular tissue without perceptible epithelial lining (Figure C). The inner aspect of the cyst wall was composed of laminated, hyalinized fibrous tissue, and the outer aspect was composed of well-formed smooth muscle layers without a nerve plexus or ganglion cells. Elastin stain showed fragmented elastin fibers between muscle layers without definite elastic lamina. Thus, cyst formation from an artery can be ruled out. Results of immunohistochemical studies for CK and CD34 for identification of residual cystic lining epithelium are negative, and thus, duplication cyst can be ruled out. The final diagnosis was a mesenteric cyst in mesenterium of proximal jejunum, 20 cm distal from the Treitz ligament. Mesenteric cysts are commonly located in the ileal mesentery, but they can be found anywhere in the mesentery from the duodenum to the rectum.1 The incidence of mesenteric cysts has been estimated to be 1:100,000 in the adult population, with a male:female ratio of 1:1.2 The pathogenesis of the disease remains obscure, and many pathologic processes have been reported, including benign proliferation of ectopic lymphatic vessels, obstruction of lymphatic vessels, abdominal trauma, and degeneration of lymph nodes. Abdominal pain, nausea, and vomiting are the most frequent symptoms. At present, preoperative diagnosis is facilitated using ultrasonography, CT, and magnetic resonance imaging. Total cystectomy is the therapeutic method of choice, even in those cases requiring intestinal resection. Total resection reduces the recurrence rate, and can prevent potential malignant degeneration of the cyst. Open or laparoscopic surgical excision may be performed in cases where a mesenteric cyst is suspected because of symptoms, or when the nature of the mass is unknown preoperatively.3 References 1. Aydinli B, Yildirgan MI, Kantarci M, et al. Giant mesenteric cyst. Dig Dis Sci 2006;51:1380 –1382. 2. Menon P, Rao KL, Vaiphei K. Isolated enteric duplication cysts. J Pediatr Surg 2004;39:e5–7. 3. Mihmanli I, Erdogan N, Kurugoglu S, et al. Radiological workup in mesenteric cysts: insight of a case report. Clin Imaging 2001;25:47– 49. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).
Question: A 34-year-old woman presented with abdominal fullness and loss of appetite for ⬎5 months. She came to our department of surgery with the complaint of an intra-abdominal rolling mass. She had the sensation of something tumbling to the dependent portion of her abdomen when she changed position in bed. She had no history of pancreatitis or abdominal trauma. A movable, elastic mass with a smooth surface was palpated in the upper abdomen. Abdominal ultrasonography revealed a cystic mass lesion in the upper abdomen. Abdominal computed tomography (CT) scan showed a cystic mass with a thin cystic wall (Figure A). The cystic tumor had no communication with bowel or any retroperitoneal organ, such as pancreas or adrenal gland. Laparoscopy revealed an intra-mesenteric cystic tumor (Figure B), which was resected laparoscopically. The patient’s postoperative recovery was uneventful, and she remains in good health ⬎1 year postoperatively. What is the diagnosis?
See the GASTROENTEROLOGY web site (www.gastrojournal. org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. HUNG–HUA LIANG PO–LI WEI MING–TE HUANG Division of General Surgery Department of Surgery Taipei Medical University Hospital and Department of Surgery School of Medicine College of Medicine Taipei Medical University Conflicts of interest The authors disclose no conflicts. © 2011 by the AGA Institute 0016-5085/$36.00 doi:10.1053/j.gastro.2010.03.060
GASTROENTEROLOGY 2011;140:e9 – e10
e10
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI
GASTROENTEROLOGY Vol. 140, No. 3
Answer to the Clinical Challenges and Images in GI Question: Image 5: Mesenteric Cyst in Mesenterium of Proximal Jejunum Grossly, the tumor was a mesenteric cyst with a smooth inner and outer surface. No obvious hemorrhage or necrosis was noted. Microscopic examination demonstrated a cavitary lesion walled by fibromuscular tissue without perceptible epithelial lining (Figure C). The inner aspect of the cyst wall was composed of laminated, hyalinized fibrous tissue, and the outer aspect was composed of well-formed smooth muscle layers without a nerve plexus or ganglion cells. Elastin stain showed fragmented elastin fibers between muscle layers without definite elastic lamina. Thus, cyst formation from an artery can be ruled out. Results of immunohistochemical studies for CK and CD34 for identification of residual cystic lining epithelium are negative, and thus, duplication cyst can be ruled out. The final diagnosis was a mesenteric cyst in mesenterium of proximal jejunum, 20 cm distal from the Treitz ligament. Mesenteric cysts are commonly located in the ileal mesentery, but they can be found anywhere in the mesentery from the duodenum to the rectum.1 The incidence of mesenteric cysts has been estimated to be 1:100,000 in the adult population, with a male:female ratio of 1:1.2 The pathogenesis of the disease remains obscure, and many pathologic processes have been reported, including benign proliferation of ectopic lymphatic vessels, obstruction of lymphatic vessels, abdominal trauma, and degeneration of lymph nodes. Abdominal pain, nausea, and vomiting are the most frequent symptoms. At present, preoperative diagnosis is facilitated using ultrasonography, CT, and magnetic resonance imaging. Total cystectomy is the therapeutic method of choice, even in those cases requiring intestinal resection. Total resection reduces the recurrence rate, and can prevent potential malignant degeneration of the cyst. Open or laparoscopic surgical excision may be performed in cases where a mesenteric cyst is suspected because of symptoms, or when the nature of the mass is unknown preoperatively.3 References 1. Aydinli B, Yildirgan MI, Kantarci M, et al. Giant mesenteric cyst. Dig Dis Sci 2006;51:1380 –1382. 2. Menon P, Rao KL, Vaiphei K. Isolated enteric duplication cysts. J Pediatr Surg 2004;39:e5–7. 3. Mihmanli I, Erdogan N, Kurugoglu S, et al. Radiological workup in mesenteric cysts: insight of a case report. Clin Imaging 2001;25:47– 49. For submission instructions, please see the GASTROENTEROLOGY web site (www.gastrojournal.org).