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Ascitis final


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Ascitis final

  1. 1. MD Ped PhD Ped and children special need
  2. 2. Personal history  Raania M A 4-year-old girl from weish Dk first kid of non cosanguious marriage with low social state
  3. 3. Complaint  Patient referred for evaluation of abdominal enlargement low grade nocturnal fever
  4. 4. History of the present illness  She was born at full term, and her growth and development were normal. Her past medical history was unremarkable  until she presented with abdominal distension and mild constipation at the age of 36 months.  No other symptoms were present at that time.  There was no family history of gastrointestinal disorders, liver or pancreas disease, or cancer. There was no history of allergy to medication and her immunizations were up to date.
  5. 5.  On admission she appeared healthy.  Her vital signs were normal and fever peak 38c.  Weight and height were in the 50th percentile.  She had no adenopathy,, or jaundice.  Chest : BEAE  Heart S1 S2 O  .The abdomen was distended, soft and nontender, with no masses palpable. A wave was felt but there was no shifting dullness.  The spleen and liver were not enlarged.  Neurologic exam was normal.  The remainder of the physical exam was normal.
  6. 6.  Investigation ordere CBCs TLC:9.6 RBCs: 3.64 HB: 10 PLAT: 296  Total serum protein, 7.3 g/dL;  serum albumin, 4.2 g/dL;  serum cholesterol, 153 serum lactate dehydrogenase;320 uric acid; 3.6 liver enzyme (ALT 25 mg, AST 30, ,alkaline phosphatase 370 KAU gamma glutamyltransferase;118 prothrombin time 12 and international normalized ratio1.1 Thyroid function tests; urine analysis. Normal finding A tuberculin skin test was negative
  7. 7.  Radiological study ordere  CXR : normal finding  The ultrasound abdominal Ex Revealed: A large fluid collection with septation. The collection extended from the upper abdomen to the pelvis. The bowel loops were displaced posteriorly. The liver, spleen, and pancreas were normal. A Doppler study showed normal portal and splenic venous and arterial flow .The inferior vena cava and the aorta appeared normal.
  8. 8.  Radiological studyordere Axial tomograph  Abdominal CT scan report A large amount of intraperitoneal fluid and no definite septation. The fluid surrounded the organs including the spleen, The bowel was compressed in the midline around the mesentery. The liver was normal in size and contour and enhanced homogeneously without evidence of focal lesion. There was no intrahepatic biliary dilatation seen. The spleen was normal in size and enhanced homogeneously. The pancreas, adrenal glands, and kidneys were normal and there were no masses present in the abdomen or the pelvis.
  9. 9. NEXT STEP INVASIVE MANOVER  A paracentesis was performed  Aspiration of 650 mL of yellow fluid was removed.
  10. 10.  A paracentesis fluid Analysis bacteriological and biochemical  revealed the following: no bacteria on Gram stain; negative bacterial culture;  WBC count,( 620 cells/mm3; with 84% lymphocytes,  7% histiocytes, and 8% eosinophils;)  Total protein, 3.7 g/dL;  Albumin, 1.9 g/dL;  Cholesterol, 63 mmol/L; Triglycerides, 25 mmol/L; Amylase < 30 mmol/L; and lactate, 0.9 mmol/L.  The serum glucose was 95 mg/dL;
  11. 11. WHAT ELSE how manage
  12. 12.  Surical Exploration:  Laparotomy was performed  A large multicystic mass, 22 × 18 × 2.8 cm, weighing 1840 g was found beneath the peritoneum. It originated from the omentum and had a narrow pedicle. The walls were thin and translucent septa were present. 
  13. 13. Histopathological study  Histologic analysis revealed cystic spaces lined by flat endothelial cells. Aggregates of lymphoid tissue were seen in the wall of the cysts, which were composed of vessels and adipose tissue.
  14. 14. Final Etiologic Diagnosis  Omental cyst.  Surgically removed and the child is doing well.
  15. 15.  Cystic lesion of the omentum and mesentery are rare. The incidence of both cyst types has been variously reported to vary from 1/27,000-100,000 hospital admission. Omental cysts occur three to ten times less frequently than mesenteric cyst. Preoperative diagnosis is infrequently made because of lack of characteristic symptoms and signs.  Cystic lesion of the omentum, mesentery and retroperitoneum have been grouped together in the same category by several authors because they are similar embryologically and pathologically
  16. 16.  According to Conzo et al [1], mesenteric and omental cysts are congenital abdominal lesions. However, most reported cases as in this presentation occurred in adult, while only about one third of cases are reported in children younger than 15 years [2]. Probably, the benign nature of these cysts, their generally asymptomatic nature unless when complicated and the non-hindrance on patient day to day activities makes affected patient not to present for medical attention until gross abdominal swelling had set in
  17. 17.  Omental cysts are usually differentiated from ascites by the fact that it is not associated with flanks bulging during recumbency since the cyst will follow as the patient moves.  Ultrasonography in this patient revealed multiseptated cyst having some solid components and features suggestive of internal haemorrhage.
  18. 18.  The goal of surgical therapy is complete excision of the mass, which sometimes may require inclusion of the adjacent structures  The goal of surgical therapy is complete excision of the mass, which sometimes may require inclusion of the adjacent structures
  19. 19.  1-Conzo G, Vacca R, Grazia Esposito M, Brancaccio U, Celsi S, Livrea A. Laparoscopic treatment of an omental cyst: a case report and review of the literature. Surg Laparosc Endosc Percutan Tech. 2005;15:33–35.  2-Rahman GA, Johnson A-WBR. Giant Omental Cyst simulating ascites in a Nigerian Child: case report and critique of clinical parameters and investigative modalities. Ann Trop Paediatr. 2001;21:81–85. doi: 10.1080/02724930020028975