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Case Presentation
Dr. Afzal Ferdoush
Resident Medical Officer
Department of Pediatric Surgery
Particulars Of The Patient
 Name: Master A
 Age:6 years
 Sex: Male
 Address: Feni
Chief Complaints
 Recurrent Peri-umbilical pain for 1 year.
 History of vomiting during attack of pain for same duration
 History of occasional fever
H/O Present illness
According to the statement of the patient’s mother, her child’s presenting
complaints started 1 year back.
Pain was around the umbilicus and colicky in nature which occurs 5 to 6
times last 1 year.
Patient gave also history of non-bilious vomiting during attack of pain and
history of occasional low grade fever.
.
.
H/O Present Illness (cont’d.)
But pain was not associated with abdominal distension or constipation
For which he was admitted in Feni Sadar hospital and managed
conservatively. They did several investigations for evaluation of the
cause and USG of abdomen revealed, a complex cyst in right lumber
region (29x24)mm.
H/O Present Illness (cont’d.)
Patient referred to BSMMU and USG report was suggestive of a thick
wall cyst having incomplete septation & low level echoes (32x26x6)mm is
noted in right pelvic cavity near urinary bladder.
Then patient got admitted under Department of Pediatric Surgery
Birdem General Hospital (Mohila O Shisu) for further management..
 History of past illness : Nothing significant.
 Birth history:
The boy was the 1st issue of the parents.
 Developmental history:
Developmental milestones : As per age
 Family history:
Nothing-contributory
 Treatment history
Syp.Algin
Syp.Omidon
Syrp.Famotack
 Socioeconomic history
Middle socioeconomic status
 Immunization history
Immunized as per EPI schedule
General examination
 Appearance : Playfull
 Decubitus : supine
 Weight : 18kg
 Anemia : absent
 Jaundice : absent
 Edema : absent
 Hydration status:normal
 Clubbing : absent
 Lymph nodes : not palpable
 Respiratory rate : 25 breaths/min
 Pulse : 96 beats/ min
 BP:90/60 mm of Hg
 Temperature:98.4°F
Local Examination
• Inspection: Abdomen not distended & No visible mark identified
• Palpation: Abdomen soft, non-tender,
mobile lump in right lower abdomen.
• Percussion: Tympanic.
• Auscultation: Bowel sound present
D/R/E: Normal.
Other systems revealed no abnormality
PROVISIONAL DIAGNOSIS
Provisional diagnosis
Mesenteric cyst
Differential Diagnosis
Differential Diagnosis
 Cystic teratoma
 Omental cyst
 Hydatid cyst
USG of Whole Abdomen
A well defined cystic area with thick wall
margin with multiple thick septations with
internal echogenic debris in the right
lower abdomen measuring (3.5x3)cm
Comment: Multisepted thick wall cystic
lesion in right lower abdomen and right
ilac fossa.Possibility of mesenteric cyst
CT scan Whole Abdomen
Cont’d..
 Findings: A cystic lesion about (3.1x3.1x3)cm at the interface of right
lumber and iliac fossa region. The lesion is showing mildly thick wall
measuring about 2.8 to 3 mm. Few internal septation’s are observed
within the lesion. Interrupted calcifications are seen in the wall of lesion.
Post contrast scan revealed minimal marginal and internal septal
enhancement of the lesion.
 Comment: Possibility of Mesenteric cyst of right lumber and iliac fossa.
Chest X-Ray P/A View
Comment: Normal study
Lab Investigations
INV. FINDINGS
CBC with ESR Hb: 12.9gm/dl, WBC: 5030 /ccm, N: 26% L: 61% E: 10%,
PLT: 240000/ccm, ESR: 10 mm/1st hr
BT
CT
2 min. 15 sec.
6 min. 45 sec.
S.Electrolytes Na: 136 mmol/l, K:3.6mmol/l, Cl: 100mmol/l, HCO3: 24mmol/l
S.Creatinine 0.48mg/dl
S.Amaylase 40U/L
Blood group B Positive
RBS 5.8 mmol/l
RAT Negative
Clinical diagnosis
Mesenteric cyst
Management
 Counseling of parents for treatment options.
 Preanaesthetic checkup
 Informed written consent was taken.
Operation note
 Name of operation: Excision of mesenteric cyst
 Indication: Mesenteric cyst
 Anesthesia: G/A
 Patients position : Patient was placed in supine position.
 Incision: A transverse incision made on right lower abdomen
Cont’d
After entering peritoneal cavity, an
intact cyst (Type-1) was exteriorized
which was arising from the terminal
ileal mesentery. Intra-operative image
showed the intact cyst size about
(3.5x3)cm
Operation note (Cont’d..)
 The cyst was excised in toto. The
rest of the bowel was splayed around
it and was healthy. Abdomen was
closed in layers.
Operation note ( Cont’d..)
 On cutting it open, it was filled with
whitish fluid.
Final diagnosis
Mesenteric cyst-Type 1
Post-operative period
Post-operative period was uneventful.
He was discharged on 4th postoperative day with advice for follow up
after 7 days with histopathology report.
Histopathology
Microscopic description:
 Cut sections show cyst wall composed of fibromuscular tissue.
 Focal area is lined by tall columnar epithelium. Subepithelial tissue is
infiltrated by acute and chronic inflammatory cells.
 No granuloma or malignancy seen.
Follow up
 No complaints
 Bowel and bladder habit was normal
 On examination
 Abdomen-soft, non tender
 Wound- healthy
Take Home Messages
 In asymptomatic cases early surgery advised to avoid acute abdominal
catastrophic like cyst hemorrhage, rupture,volvulus etc..
 Meticulous surgery needed to avoid gut injury and recurrence.
Thanks all
Short discussion
A mesenteric cyst is formed of fluid collection between the two layers
of small bowel mesentery.
Types and etiology
Chylolymphatic cyst.
 Enterogenous cyst.
 Dermoid cyst.
 Cyst of urogenital remnants.
Presentation
• Mesenteric cyst mostly discovered incidentally.
• Symptoms
Abdominal distension
Abdominal pain
Mass may be palpable
Approximately 10% of patients with mesenteric cyst present with
an acute abdominal emergency, the most common picture is small
bowel obstruction.
Treatment
• Enucleation:The preferred treatment of mesenteric cyst
of chylolymphatic origin.
• Excision and intestinal ressention is frequently required to ensure that
the remaining bowel is viable
• Partial excision with marsupialization If enucleation or resection is not
possible because of the size of cyst or because of it’s location deep
within the root of mesentery
CONT.
• Laparascopic management: Could be used to localize the cyst
and resection could be performed through a small laparatomy or via
an extended umbillical incision.
• Ultrasound guided drainage has also reported to be successful.
References
1. Raffensperger JG. Idiopathic intussusceptions. Swenson’s Paediatric Surgery. Vol. 2. 5th edition 1990: p. 1182-5.
2. Tander B, Baskin D, Candan M, Basak M, Bankoglu M. Ultrasound guided reduction of intussusception with saline
and comparison with operative treatment. Ulus Travma Acil Cerrahi Derg 2007;13:288-93.
3. Mayell MJ. Intussusception in infancy and childhood in Southern Africa. A review of 223 cases. Arch Dis Child
1972;47:20-5.
4. DiFiore JW. Intussusception. Semin Pediatr Surg 1999;8:214-20.
5. Baracchini A, Chiaravalloti G, Quinti S, Rossi A, Favili T, Ughi C, et al. Intestinal intussusception in children. Minerva
Pediatr 1995;47:215-9.
6. Odita JC, Piserchia NE, Diakporomre MA. Childhood intussusception in Benin City, Nigeria. Trop Geogr Med
1981;33:317-21.
7. Sigmound EH, Daneeman A. Intussussception. In: Grosfeld JL, O’Neil JA, Fonkalsrud EW, editors. Paediatric
Surgery. 6th ed. Philadelphia: Mosby Year Book Inc.; 2006. p. 1313-41.
8. Grant HW, Buccimazza I, Hadley GP. A comparison of colo-colic and ileo-colic intussusception. J Pediatr Surg
1996;31:1607-10

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MESENTERIC CYCT .pptx

  • 2. Case Presentation Dr. Afzal Ferdoush Resident Medical Officer Department of Pediatric Surgery
  • 3. Particulars Of The Patient  Name: Master A  Age:6 years  Sex: Male  Address: Feni
  • 4. Chief Complaints  Recurrent Peri-umbilical pain for 1 year.  History of vomiting during attack of pain for same duration  History of occasional fever
  • 5. H/O Present illness According to the statement of the patient’s mother, her child’s presenting complaints started 1 year back. Pain was around the umbilicus and colicky in nature which occurs 5 to 6 times last 1 year. Patient gave also history of non-bilious vomiting during attack of pain and history of occasional low grade fever. . .
  • 6. H/O Present Illness (cont’d.) But pain was not associated with abdominal distension or constipation For which he was admitted in Feni Sadar hospital and managed conservatively. They did several investigations for evaluation of the cause and USG of abdomen revealed, a complex cyst in right lumber region (29x24)mm.
  • 7. H/O Present Illness (cont’d.) Patient referred to BSMMU and USG report was suggestive of a thick wall cyst having incomplete septation & low level echoes (32x26x6)mm is noted in right pelvic cavity near urinary bladder. Then patient got admitted under Department of Pediatric Surgery Birdem General Hospital (Mohila O Shisu) for further management..
  • 8.  History of past illness : Nothing significant.  Birth history: The boy was the 1st issue of the parents.  Developmental history: Developmental milestones : As per age  Family history: Nothing-contributory
  • 9.  Treatment history Syp.Algin Syp.Omidon Syrp.Famotack  Socioeconomic history Middle socioeconomic status  Immunization history Immunized as per EPI schedule
  • 10. General examination  Appearance : Playfull  Decubitus : supine  Weight : 18kg  Anemia : absent  Jaundice : absent  Edema : absent  Hydration status:normal  Clubbing : absent  Lymph nodes : not palpable  Respiratory rate : 25 breaths/min  Pulse : 96 beats/ min  BP:90/60 mm of Hg  Temperature:98.4°F
  • 11. Local Examination • Inspection: Abdomen not distended & No visible mark identified • Palpation: Abdomen soft, non-tender, mobile lump in right lower abdomen. • Percussion: Tympanic. • Auscultation: Bowel sound present D/R/E: Normal. Other systems revealed no abnormality
  • 15. Differential Diagnosis  Cystic teratoma  Omental cyst  Hydatid cyst
  • 16. USG of Whole Abdomen A well defined cystic area with thick wall margin with multiple thick septations with internal echogenic debris in the right lower abdomen measuring (3.5x3)cm Comment: Multisepted thick wall cystic lesion in right lower abdomen and right ilac fossa.Possibility of mesenteric cyst
  • 17. CT scan Whole Abdomen
  • 18. Cont’d..  Findings: A cystic lesion about (3.1x3.1x3)cm at the interface of right lumber and iliac fossa region. The lesion is showing mildly thick wall measuring about 2.8 to 3 mm. Few internal septation’s are observed within the lesion. Interrupted calcifications are seen in the wall of lesion. Post contrast scan revealed minimal marginal and internal septal enhancement of the lesion.  Comment: Possibility of Mesenteric cyst of right lumber and iliac fossa.
  • 19. Chest X-Ray P/A View Comment: Normal study
  • 20. Lab Investigations INV. FINDINGS CBC with ESR Hb: 12.9gm/dl, WBC: 5030 /ccm, N: 26% L: 61% E: 10%, PLT: 240000/ccm, ESR: 10 mm/1st hr BT CT 2 min. 15 sec. 6 min. 45 sec. S.Electrolytes Na: 136 mmol/l, K:3.6mmol/l, Cl: 100mmol/l, HCO3: 24mmol/l S.Creatinine 0.48mg/dl S.Amaylase 40U/L Blood group B Positive RBS 5.8 mmol/l RAT Negative
  • 22. Management  Counseling of parents for treatment options.  Preanaesthetic checkup  Informed written consent was taken.
  • 23. Operation note  Name of operation: Excision of mesenteric cyst  Indication: Mesenteric cyst  Anesthesia: G/A  Patients position : Patient was placed in supine position.  Incision: A transverse incision made on right lower abdomen
  • 24. Cont’d After entering peritoneal cavity, an intact cyst (Type-1) was exteriorized which was arising from the terminal ileal mesentery. Intra-operative image showed the intact cyst size about (3.5x3)cm
  • 25. Operation note (Cont’d..)  The cyst was excised in toto. The rest of the bowel was splayed around it and was healthy. Abdomen was closed in layers.
  • 26. Operation note ( Cont’d..)  On cutting it open, it was filled with whitish fluid.
  • 28. Post-operative period Post-operative period was uneventful. He was discharged on 4th postoperative day with advice for follow up after 7 days with histopathology report.
  • 29. Histopathology Microscopic description:  Cut sections show cyst wall composed of fibromuscular tissue.  Focal area is lined by tall columnar epithelium. Subepithelial tissue is infiltrated by acute and chronic inflammatory cells.  No granuloma or malignancy seen.
  • 30. Follow up  No complaints  Bowel and bladder habit was normal  On examination  Abdomen-soft, non tender  Wound- healthy
  • 31. Take Home Messages  In asymptomatic cases early surgery advised to avoid acute abdominal catastrophic like cyst hemorrhage, rupture,volvulus etc..  Meticulous surgery needed to avoid gut injury and recurrence.
  • 33. Short discussion A mesenteric cyst is formed of fluid collection between the two layers of small bowel mesentery. Types and etiology Chylolymphatic cyst.  Enterogenous cyst.  Dermoid cyst.  Cyst of urogenital remnants.
  • 34. Presentation • Mesenteric cyst mostly discovered incidentally. • Symptoms Abdominal distension Abdominal pain Mass may be palpable Approximately 10% of patients with mesenteric cyst present with an acute abdominal emergency, the most common picture is small bowel obstruction.
  • 35. Treatment • Enucleation:The preferred treatment of mesenteric cyst of chylolymphatic origin. • Excision and intestinal ressention is frequently required to ensure that the remaining bowel is viable • Partial excision with marsupialization If enucleation or resection is not possible because of the size of cyst or because of it’s location deep within the root of mesentery
  • 36. CONT. • Laparascopic management: Could be used to localize the cyst and resection could be performed through a small laparatomy or via an extended umbillical incision. • Ultrasound guided drainage has also reported to be successful.
  • 37. References 1. Raffensperger JG. Idiopathic intussusceptions. Swenson’s Paediatric Surgery. Vol. 2. 5th edition 1990: p. 1182-5. 2. Tander B, Baskin D, Candan M, Basak M, Bankoglu M. Ultrasound guided reduction of intussusception with saline and comparison with operative treatment. Ulus Travma Acil Cerrahi Derg 2007;13:288-93. 3. Mayell MJ. Intussusception in infancy and childhood in Southern Africa. A review of 223 cases. Arch Dis Child 1972;47:20-5. 4. DiFiore JW. Intussusception. Semin Pediatr Surg 1999;8:214-20. 5. Baracchini A, Chiaravalloti G, Quinti S, Rossi A, Favili T, Ughi C, et al. Intestinal intussusception in children. Minerva Pediatr 1995;47:215-9. 6. Odita JC, Piserchia NE, Diakporomre MA. Childhood intussusception in Benin City, Nigeria. Trop Geogr Med 1981;33:317-21. 7. Sigmound EH, Daneeman A. Intussussception. In: Grosfeld JL, O’Neil JA, Fonkalsrud EW, editors. Paediatric Surgery. 6th ed. Philadelphia: Mosby Year Book Inc.; 2006. p. 1313-41. 8. Grant HW, Buccimazza I, Hadley GP. A comparison of colo-colic and ileo-colic intussusception. J Pediatr Surg 1996;31:1607-10