|Year : 2019 | Volume
| Issue : 2 | Page : 163-165
Mesenteric cyst in a 6-years old: A case report and review of literature
Felix Emeka Menkiti1, Corelius Ozobia Ukah1, Jideofor Okechukwu Ugwu2
1 Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
2 Department of Paediatric Surgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
|Date of Submission||18-Mar-2019|
|Date of Decision||01-Apr-2019|
|Date of Acceptance||25-May-2019|
|Date of Web Publication||6-Dec-2019|
Dr. Felix Emeka Menkiti
Department of Histopathology, Nnamdi Azikiwe University Teaching Hospital, PMB 5025, Nnewi, Anambra State
Source of Support: None, Conflict of Interest: None
Mesenteric cysts (MCs) are a group of rare benign intra-abdominal lesions that are usually asymptomatic but with chances of recurrence and malignant transformation if incompletely excised. Its asymptomatic or nonspecific symptomatic nature makes preoperative diagnosis difficult. We report a case of huge congenital MC in a 6 years old. He was brought to our center following a history of recurrent abdominal pain since birth. The diagnosis was suggested following computed tomography scan but only confirmed postlaparotomy through histopathologic evaluation. No recurrence on follow-up has been reported.
Keywords: Chylous fluid, intraabdominal, mesenteric cyst
|How to cite this article:|
Menkiti FE, Ukah CO, Ugwu JO. Mesenteric cyst in a 6-years old: A case report and review of literature. Ann Trop Pathol 2019;10:163-5
| Introduction|| |
Mesenteric cyst (MC) is a rare intra-abdominal lesion thought to occur exclusively in childhood,, but is now known to affect any age. It occurs in the adult population with an estimated incidence of 1 in 100,000 and the pediatric population with an estimated incidence of 1 in 20,000.,, Most cases are asymptomatic and discovered incidentally or as a result of its complications. When symptomatic, it presents with abdominal pain, and about 10% of the cases are associated with intestinal obstruction, volvulus, or torsion.,,, It is believed to result from failed coalescence of mesothelial lined structures, while another school of thought believes it to represent ectopic lymphatic tissue lacking communication with the lymphatic drainage system, hence chylous cyst., MC can occur anywhere along the mesentery of the gastrointestinal tract. A large series review of 162 patients by Kurtz et al. revealed that 60% occurred in the small-bowel mesentery, 24% in the large-bowel mesentery, and 14.5% in the retroperitoneum. Due to the rarity of this entity and the lack of specific symptoms, correct preoperative diagnosis is difficult. Knowledge of these lesions is important due to the various complications associated with suboptimal surgical management.
| Case Report|| |
A 6-year-old boy brought by his parents with complaints of centrally located abdominal pain from birth initially characterized by frequent excessive crying and restlessness at infancy and later became evidently colicky with a frequency of once in 2 months. The pains were usually severe, nonradiating and with no known aggravating factors but were usually relieved by bouts of vomiting which were occasionally bilious. Two years before presentation, the frequency of bouts of pain became weekly. There was no abdominal swelling, change in bowel habit, or weight loss. He was said to have continued to make adequate urine without any lower urinary tract symptom. Owing to the above symptoms, he had been taken to several hospitals and had traditional scarifications performed on him before presenting to the referring hospital where abdominal computerized tomographic (CT) scan was done before referral.
Examination revealed multiple scarification marks on the right lower abdominal quadrant. There was no palpable mass per abdomen. The full blood count and blood chemistry were within normal limits. The accompanying abdominal CT and ultrasound (US) scans demonstrated a huge mixed density mass more on the right lower abdomen abutting the umbilicus superiorly and the bladder inferiorly, and the possibility of urachal cyst or MCs was entertained. He had exploratory laparotomy with the findings of a huge multi-septated mass measuring 14.0 cm × 12.0 cm, located in the mesentery of the proximal ileum abutting the mesenteric border of the ileum [Figure 1]. There was associated midgut volvulus rotated about 180° in the clockwise direction and surrounded by engorged vessels. The volvulus was relieved; a segmental ileal resection en bloc with the mass and an end-to-end ileal anastomosis was done. The patient had no complication, recovered and was discharged home after 8 days on admission. The resected ileum and mass were sent for histology.
|Figure 1: Surgical picture showing the lesion within the mesentery of the small intestine|
Click here to view
Microscopy of the chylous fluid containing multilocular cystic mass showed multilocular cyst lined by mono-layered flattened nonatypical epithelium surrounded by fibrous wall containing clusters of lymphocytes and cholesterol crystals [Figure 2]a and b]. The intestinal tissue was essentially normal, while the accompanying lymph node showed reactive sinus hyperplasia
|Figure 2: (a) Histologic section showing multilocular cyst containing lymphocytes and cholesterol crystals within the fibrous wall and the cyst lumina (H and E, ×100). (b) Histologic section showing lymphocytes within the wall of the cyst (H and E, ×100)|
Click here to view
| Discussion|| |
MCs are a group of rare intra-abdominal benign growths occurring in the mesentery of the gut, with reported malignant transformation in about 3%., They can occur anywhere along the length of the intestine, more commonly involving the small intestine (about 60%) than the large intestine., It may also be retroperitoneal. MC was described by Benevieni, an Italian anatomist in 1507 while performing autopsy on an 8-year old boy.,
Almost any age can be affected, but most of the cases occur in children and adolescents with >50% occurring before the age of two. The reported incidence of MC is 1 in 100,000 in the adult population and 1 in 20,000 in the pediatric population.,, There could be an under-reporting of the cases as most are asymptomatic. The symptoms are nonspecific, and the clinical presentations include common symptoms of the gastrointestinal tract, but can rarely be complicated by rupture, torsion, or intestinal obstruction causing acute and intense symptoms. The index patient presented with features of recurrent intestinal obstruction, and the MC was found to be associated with volvulus.
MCs could be congenital or acquired. The congenital cases are believed to arise from incomplete fusion of the mesothelium-lined peritoneal surfaces or proliferating ectopic lymphatic tissues lacking communication with the lymphatic drainage system.,, This may explain the different cyst contents, namely chylous and serous. The acquired cases are believed to be a result of blockage of communication of lymph nodes with the lymphatics and venous system or blockage of draining lymphatics as a result of trauma, neoplasm, or infection. Beahrs et al. in 1950, proposed an etiological classification of MCs into four groups: Congenital/developmental, traumatic, neoplastic, and infectious/degenerative. The index case could be classified as congenital since the history was since birth.
The index case had normal hematological parameters, electrolytes, and blood urea and creatinine. The diagnosis of MC was only suggested on abdominal ultrasonogram and CT scan, which was confirmed histologically. The preoperative diagnosis of MCs is usually difficult clinically, and plain radiographs are often normal or nonspecific., Literature has shown that US scan, CT scan, especially contrast enhanced, and magnetic resonance imaging are very helpful.,, The diagnosis is proven on laparotomy and has to be histologically confirmed.
Complete excision of the cyst is curative with an excellent prognosis, reducing chances of recurrence and malignant transformation. The extent of surgery is linked to the recently proposed pathologic classification system: Types 1 (Pedunculated) and 2 (Sessile) are limited to the mesentery and can be excised completely with or without resection of the involved gut; types 3 (unicentric) and 4 (multicentric) on the other hand, have retroperitoneal extension and may require complex operations with marsupialization or sclerotherapy. The index case was located in the mesentery of the ileum, had no retroperitoneal extension, and the lesion was excised with ileal resection and anastomosis.
| Conclusion|| |
MCs are rare benign intra-abdominal cystic lesions often complicated by intestinal obstruction. It is often missed due to its vague symptoms and asymptomatic nature but associated with excellent postexcision prognosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Yoon JW, Choi DY, Oh YK, Lee SH, Gang DB, Yu ST. A case of mesenteric cyst in a 4-year-old child with acute abdominal pain. Pediatr Gastroenterol Hepatol Nutr 2017;20:268-72.
de Perrot M, Bründler M, Tötsch M, Mentha G, Morel P. Mesenteric cysts. Toward less confusion? Dig Surg 2000;17:323-8.
Challa SR, Senapati D, Nulukurthi TK, Chinamilli J. Mucinous mesenteric cyst of the sigmoid mesocolon: A rare entity. BMJ Case Rep 2016;2016. pii: bcr2015210411.
Kwan E, Lau H, Yuen WK. Laparoscopic resection of a mesenteric cyst. Gastrointest Endosc 2004;59:154-6.
Braquehage J. Des kystes du mesentery. Arch Gen 1892;170:291.
El-Agwany AM. Huge mesenteric cyst: Pelvic cysts differential diagnoses dilemma. Egypt J Radiol Nucl Med 2016;47:373-6.
Yoon HK, Han BK. Chronic midgut volvulus with mesenteric lymphangioma: A case report. Pediatr Radiol 1998;28:611.
Weeda VB, Booij KA, Aronson DC. Mesenteric cystic lymphangioma: A congenital and an acquired anomaly? Two cases and a review of the literature. J Pediatr Surg 2008;43:1206-8.
Prakash A, Agrawal A, Gupta RK, Sanghvi B, Parelkar S. Early management of mesenteric cyst prevents catastrophes: A single centre analysis of 17 cases. Afr J Paediatr Surg 2010;7:140-3.
] [Full text]
Ousadden A, Elbouhaddouti H, Ibnmajdoub KH, Harmouch T, Mazaz K, Aittaleb K. A giant peritoneal simple mesothelial cyst: A case report. J Med Case Rep 2011;5:361.
Miljković D, Gmijović D, Radojković M, Gligorijević J, Radovanović Z. Mesenteric cyst. Arch Oncol 2007;15:91-3.
Richard RR. Mesenteric and omental cysts. In: Grosfeld JL, O'Neill JA Jr., Coran AG, Fonkalsrud EW, editors. Pediatric Surgery. 6th
ed.. Philadelphia: Mosby, Elsevier; 2006. p. 1399-406.
Navarro F, Schmieler E, Beversdorf W. Infarcted mesothelial cyst: A case report. Int J Surg Case Rep 2017;30:155-8.
Kurtz RJ, Heimann TM, Holt J, Beck AR. Mesenteric and retroperitoneal cysts. Ann Surg 1986;203:109-12.
Pithawa AK, Bansal AS, Kochar SP. Mesenteric cyst: A rare intra-abdominal tumour. Med J Armed Forces India 2014;70:79-82.
Kınaş V, Gülben K, Berberoǧlu U, Bekar ME. Mesenteric cystic lymphangioma: A case report. South Clin Ist Euras 2016;27:258-60.
Beahrs OH, Judd ES Jr., Dockerty MB. Chylous cysts of the abdomen. Surg Clin North Am 1950;30:1081-96.
Huis M, Balija M, Lez C, Szerda F, Stulhofer M. Mesenteric cysts. Acta Med Croatica 2002;56:119-24.
Fernández Ramos J, Vázquez Rueda F, Azpilicueta Idarreta M, Díaz Aguilar C. Mesothelial giant cyst of great omentum. An Pediatr (Barc) 2009;71:180-1.
Rattan KN, Nair VJ, Pathak M, Kumar S. Pediatric chylolymphatic mesenteric cyst – A separate entity from cystic lymphangioma: A case series. J Med Case Rep 2009;3:111.
Krishna M, Kumar M. A masquerading mesenteric cyst. Oncol Cancer Case Rep 2016;2:121.
Losanoff JE, Richman BW, El-Sherif A, Rider KD, Jones JW. Mesenteric cystic lymphangioma. J Am Coll Surg 2003;196:598-603.
[Figure 1], [Figure 2]