abdominal imaging volume 16 issue 1 1991 [doi 10.1007_bf01887376] yi -hong chou; chui -mei tiu; wing...

8/10/2019 Abdominal Imaging Volume 16 issue 1 1991 [doi 10.1007_bf01887376] Yi -Hong Chou; Chui -Mei Tiu; Wing -Yiu Lui

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Gastrointest Radiol 16:311-314 (1991)

Gastrointestinal

Radiology

9 Springer-Verlag New York Inc. 1991

M es en t er i c a n d O m en t a l Cy s t s : An Ul t ra s o n o g ra p h i c a n d C l i n i ca l

S t u d y o f 1 5 P a t i en t s

Y i - H o n g C h o u , 1 C h u i - M e i T i u ] W i n g - Y i u L u i , 2 a n d T s u e n C h a n g ~

Depa rtments of 1 Radiology and ~ Surgery, V eterans G eneral Hosp ital-Taipei, and N ational Yang-Ming Me dical College, Taipei,

Taiwan, Republic of China

A b s t r a c t

T h e c l i n i c a l a n d u l t r a s o n o g r a p h i c ( U S )

f e a t u r e s o f 15 c a s e s o f m e s e n t e r i c o r o m e n t a l c y s t

a r e h e r e i n d e s c r i b e d . T h i s s e r i e s i n c l u d e d s e v e n

m a l e a n d e i g h t f e m a l e p a t ie n t s , w h o s e a g e r a n g e d

f r o m 2 - 8 9 y e a r s . C o r r e c t c l in i c al d ia g n o s i s w a s

m a d e i n t w o c h i l d r e n o n l y , b u t p r e o p e r a t i v e U S e x -

a m i n a t i o n a c c u r a t e l y d e m o n s t r a t e d t h e l e s i on in 1 1

o f 13 p a t i e n t s ( 8 5 ) . T h e s e c y s t i c l e s i o n s u s u a l l y

h a d a t h i n w a l l, i n t e r n a l s e p t a t i o n s , a n d f l u i d c o n t e n t

w i t h s e d i m e n t a t i o n . E n t e r i c d u p l i c a t i o n c y s t s h a d a

r e l a t i v e ly t h i c k w a l l m e r g i n g w i t h t h e m u s c l e l a y e r

o f b o w e l l o o p , a n d m u l t il o c u l a t io n w a s n o t e d m a i n l y

w i t h c y s t i c l y m p h a n g i o m a s o r p s e u d o c y s t s . T h e d i-

a g n o s t i c a n d s u r g i c a l m a n a g e m e n t o f t h e s e l e s io n s

a r e b r i e fl y r e v i e w e d a n d t h e i r U S a p p e a r a n c e is il lu s -

t r a t e d .

K e y w o r d s :

A b d o m e n , u l t r a s o u n d - M e s e n te r ic

c y st , s y m p t o m s - - O m e n t a l c y s t , d i a g n o s i s - - E n -

t e r i c d u p l i c a t i o n .

M e s e n t e r i c a n d o m e n t a l c y s t s a r e u n c o m m o n l e -

s i on s w i t h a p r e v i o u s l y r e p o r t e d i n c i d e n c e o f 1 p e r

1 0 0 - 2 5 0 t h o u s a n d h o s p i t a l a d m i s s i o n s [ 1 ] . H a r d i n

a n d H a r d y [2 ] d i a g n o s e d s ix c a s e s a m o n g 1 6 1,9 44

p a t i e n t s a n d s u g g e s t e d t h a t t h e s e l e s i o n s m i g h t h a v e

o c c u r r e d w i t h a h i g h er f r e q u e n c y t h a n e x p e c t e d .

M e s e n t e r i c a n d o m e n t a l c y s t s d o n o t h a v e s p e c i f i c

s i g n s o r s y m p t o m s t o a l l o w t h e i r c l i n i c a l d i a g n o s i s

[ 3] . S i n c e t w o i n it i a l r e p o r t s o f t h e s e s o n o g r a p h i c

a p p e a r a n c e i n 1 9 7 5 [ 4 , 5 ] , h o w e v e r , s u c h l e s i o n s

h a v e b e e n d e t e c t e d w i th a n i n c r e a si n g f r e q u e n c y [ 6 -

A d d r e s s o f f p r i n t r e q u e s t s to : Yi-Hong Chou , M.D. , Depar tmen t

o f Rad io logy , Veterans G eneral Hos p i ta l -Ta ipei , Taipei , Taiwan

11217, ROC

1 1] . T h i s a r t i c l e p r e s e n t s o u r e x p e r i e n c e w i t h 1 5 a d -

d i t i o n a l c a s e s e v a l u a t e d a t o u r i n s t i t u t i o n d u r i n g t h e

p a s t 1 2 y e a r s .

M a t e ri al s a n d M e t h o d s

Fifteen cases of mesenteric/om ental cysts were collected in Vet-

erans Gen eral Hospital--Taipei from January 1978 to Decem ber

1989. All patients were operated on du e to a bdom inal pain and/or

imaging-proved abdominal mas s. There were seven m ale and

eight fema le patients, ranging in age from 2-89 years (averag e

age, 42 years). U ltrasonography (US) was performe d in 13 of 15

patients using 3.5-5.0 M Hz transducers. T he echopatterns, inter-

nal natures, wa ll thickness, and loca lization dem onstrated by US

were rec orded. T he c linical ma nifestations, major diagnostic mo-

dalities, surgical procedures, and histologic classificaitons of the

cysts were reviewed from the chart record. The total number of

hospital admissions was obtained from the com puterized data.

R e s u l t s

T h e r e w e r e a t o t a l o f 15 p a t i e n t s w i t h p a t h o l o g i c a l l y

p r o v e n m e s e n t e r i c / o m e n t a l c y s t s in 4 7 5 ,5 0 2 a d m i s -

s i o n s d u r i n g t h e p a s t 1 2 y e a r s . T h e i n c i d e n c e w a s

1 / 3 2 , 0 0 0 . T h e h i s t o l o g i c c l a s s i f i c a t i o n i n c l u d e d c y s -

t ic l y m p h a n g i o m a ( 2 c a s e s) , e n t e r i c d u p l ic a t i o n c y s t

( 2) , m e s o t h e l i a l c y s t ( 5 ), a n d n o n p a n c r e a t i c p s e u d o -

c y s t ( 6 ) ( T a b l e 1 ) . T h e m o s t c o m m o n c l i n i c a l m a n i -

f e s t a t i o n s w e r e a b d o m i n a l p a i n ( 9 o f 1 5 p a t i e n ts ) a n d

p a l p a b l e m a s s ( 7 c a s e s ) , f o l l o w e d b y a b d o m i n a l d i s-

t e n t i o n , v o m i t i n g , a n d v a r i o u s n o n s p e c i f i c f i n d in g s .

A c o r r e c t c l in i c a l i m p r e s s i o n w a s n o t e d i n o n l y t w o

p e d i a t r i c p a t i e n t s . A b d o m i n a l f i l m s a n d / o r i n t r a v e -

n o u s u r o g r a p h y w e r e r e v i e w e d i n 1 4 p a t i e n t s , a n d

o n l y si x c a s e s ( 4 0 ) s h o w e d i n t r a a b d o m i n a l s o f t t is -

s u e m a s s . B a r i u m e n e m a i n t h r e e c h i l d r e n r e v e a l e d

m i n i m a l m a s s e f f e c t i n o n l y o n e p a t i e n t w i t h a l a r ge

m e s o t h e l i a l c y s t . E l e v e n o f th e 13 p a t i e n t s r e c e i v i n g


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312 Y-H. Chou e t a l . : Mes ent er i c and Om enta l Cys t s

F ig . 1 . An 8 9-year-o ld man wi th a l a rge mesothe l i a l cys t

arrows):

T h e l e s i o n i s e c h o - f re e , o c c u p y i n g t h e w h o l e m i d - a b d o m e n , a n d

di sp l ac ing t he smal l i n t es t i ne upward and downward . LK, left

k idney .

F ig . 2 . A 4-year-o ld boy wi th a cys t i c l ymphangioma

arrows):

Mul t ip l e sep t a

arrowheads)

are ev ident i n t h i s l obul a t ed cys t i c

mass .

F ig . 3 . A 3-year-o ld g i r l w i th an i n fec t ed pseudocys t arrows):

Smal l echogeni c s t ruc ture i n t he dependent por t i on arrowhead)

represen t s debr i s .

LK,

l e f t k idney .

F ig . 4 . A 9-year-o ld boy wi th a hemorrhagi c pseudocys t arrows):

F o r m e d , s e p t a t e d i n t e r n a l e c h o e s a r e p r e s e n t d u e t o c l o t t e d

blood . LK, l e f t k idney .

F ig . 5 . A 6-year-o ld g i r l w i th an en t e r i c dupl i ca t i on cy s t arrows):

A l arge t h i ck-wal l ed cys t i c l es ion ex t en ds t o t he i l ea l wal l arrow-

heads).

The f i ne sep t a t i on may be due t o i n fec t i on .

UB,

ur inary

bl adder .

abdominal US study had a correct diagnosis preop-

eratively (85%). The other two were misinterpreted

as cystic lesions of the ovary.

All the sonograms showed well-circumscribed,

smooth-walled, fluid-filled cystic lesions of various

sizes ranging from 3 x 3 x 2 to 25 x 20 x 20 cm

(Table 1)~ A thin-walled cystic lesion wi thout septa-

tion was mos t likely a mesothelial cyst (Fig. 1). Two

lesions showing several septa (three to five) were

proved to be cystic lymphangiomas (Fig. 2). Two

lesions showing one to three septa were mesothelial

cysts. Two lesions having multiloculated appear-

ance were a cystic lymphangi oma and a pseudocyst.

Weak internal echoes were noted in some of the

mesothelial cysts. Formed internal echoes (might be

movable and sedimentary) were evident in the cysts

with hemorrhage or infection (Figs. 3 and 4). Thick-

walled cysts were only seen in two cases of enteric

duplicat ion cysts (>3 -5 mm) (Fig. 5) and in one case

ofpseudocyst (3 mm) (Table 2). The enteric duplica-

tion cysts had their thick wall merged with the mus-

cle layer of the bowel (Fig. 5). We only diagnosed

one lesion of omental origin correctly by its US ap-

pearance. Two other lesions arising from mesocolon

were misinterpreted as mesenteric lesions preopera-

tively. The other 12 cysts were located in the mesen-

tery of the small bowel.

Computed tomography (CT) was performed in

five patients (two children and three adults). CT re-

vealed similar characterist ics as shown in US exami-

nation except that some sedimentation and septa-

tion were not demonstrated, especially those in a

pseudocyst . CT demonstrated the anatomic relation-

ship between the lesion and the surrounding struc-

tures more precisely, but added little diagnostic

information to the US findings. The operative tech-

niques used in these patients included excision or

enucleation in 13 cases. In two patients, segmental

resection of bowel in one (cystic lymphangioma),

and partial resection of the urinary bladder, as well


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Y - H . C h o u e t a l . : M e s e n t e r i c a n d O m e n t a l C y s t s

T a b l e

1. C l ass i f i ca t ion and d i agnos i s o f mesent e r i c /ome nta l cys t s

313

Class i f i ca t ion Case no . Sex/ ag e S i ze

(cm)

C o r r e c t

p r e o p e r a t i v e

U S d i a g n o s is

C y s t i c l y m p h a n g i o m a 2

E n t e r i c

dupl i ca t i on cys t 2

Meso the l i a l cys t 5

P s e u d o c y s t 6

(nonpancrea t i c )

Total 15

M/2 yr , M/6 yr 15 , 24 2 /2

F/6 yr, F/61 yr 8, 10 2/2

4 - 8 9 y r 3 - 2 5 4 / 4

(3 M, 2F)

3 - 6 4 y r 5 - 2 0 3 / 5

(2M, 4F)

2 yr -8 9 yr 3 -25 11 /13

T a b l e 2 . U S a p p e a r a n c e s o f m e s e n t e r i c / o m e n t a l c y s t s

US f i nd ings Hi s to log i c c l ass i f ica t i on

a n d n u m b e r

Thick wal l (3 -5 mm) Enter i c dupl i ca t i on cys t

P s e u d o c y s t

S e p t a

N u m e r o u s P s e u d o c y s t 2

3 - 5 C y s t i c l y m p h a n g i o m a 2

1-3 Meso the l i a l cys t 2

I n t e r n a l e c h o e s

We ak, d i f fuse Meso the l i a l cys t 2

Enter i c dupl i ca t i on cys t 1

F o r m e d s e d i m e n t s M e s o t h e l i a l c y s t 2

C y s t i c l y m p h a n g i o m a 1

P s e u d o c y s t s 1

Thin wal l , no sep t a Meso the l i a l cys t 3

P s e u d o c y s t 3

as segmental resection of terminal ileum and cecum

in the ot her (duplication cyst of the terminal ileum)

were needed. All patients were followed for 3

months to 7 years and all had uneventful recoveries.

D i s c u s s i o n

The incidence of omental and mesenteric cysts at

our hospital was 1 per 32,000 admissions, whereas

Hardi n and Ha rdy found 1 per 27,000 admissions [2].

Ros et al. [11] recently classified these lesions into

five groups, consisting of lymphangioma, enteric du-

plication, mesenteric or mesothelial cyst, and non-

pancreatic pseudocysts. They can be imaged by ab-

dominal US, but establishing their precise anatomic

location might be difficult. Omental cysts tend to

displace the small bowel loops posteriorly, in con-

trast to mesenteric cysts that are often surrounded

by small bowel loops. Clinical symptoms are mani-

fested when the lesions attain a large size: they

ranged from 1-18 cm in maximal diameter in a pre-

vious report [3] and up to 25 cm in our series. Fur-

thermore, the clinical presentation may depend

upon the location of these cystic lesions and their

associated complications, such as torsion, hemor-

rhage, infection, and rupture [13]. Abdominal pain

and distention experienced by most of our patients

mainly related to the large cyst size (8-25 cm), ex-

cept for two cases with intracystic bleeding or infec-

tion. Two other pati ents complained of enlarging ab-

dominal girth, and ascites had been suspected by the

referring physicians. However, acute episodes of se-

vere abdominal pain with nausea or vomiting may

occur following torsion of mesenteric or omental

cysts.

Excision or enucle ation of the lesions is the sur-

gical procedure of choice. In our patients, a high

cure rate was achieved (13 of 13). One patient with

cystic lymphangioma was treat ed by excision of the

cyst and segmental resection of the small bowel be-

cause of their tight adhesion and the compromised

vasculature. In ano ther patient with duplication cyst

of the terminal ileum, partial cystectomy and seg-

mental resection of ileum and cecum were per-

formed. Accidental rupture of the cysts during surgi-

cal procedure was encountered in two patients due

to their huge size which made a dissection difficult.

However, the recoveries were uneventful. US has

proved very efficient in the preoperative diagnosis of

mesenteric and omental cysts according to some

previous reports and our experiences [6, 9, 11]. In

our series, no other single imaging modal ity can pro-

vide more informat ion than US, as it can easily iden-

tify the internal septation in the cysts which may be

otherwise missed by CT scan. In this instance, a

pseudocyst should be considered first, because these

noncontrast-enhanced septa most likely result from

an old hemorrhage, which is more commonly en-

countered in a traumatic pseudocyst. A thick-walled

lesion merged with the muscle laye r of the bowel is

most likely an enteric duplication cyst because it has

a muscle layer, as well as a mucosal lining predomi-


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3 1 4 Y - H . C h o u e t a l .: M e s e n t e r i c a n d O m e n t a l C y s t s

nantly similar to that o f the adjacent alimentary tract

[14]. The fine and faint internal echoes in an enteric

duplication cyst, which may be accompani ed by in-

terlacing septa, are either due to mucus collection or

infection of the cyst.

R e f e r e n c e s

1 . S p r a g u e N F J r . M e s e n t e r i c c y s t s . A m S u r g 1960;26 :42-49

2 . H a r d i n W J , H a r d y J D . M e s e n t e r i c c y s t s . A m J S u r g

1970; 119 :640-64 5

3 . W a l k e r A R , P u t n a m T C . O m e n t a l , m e s e n t e r i c , a n d r e t ro p e r i -

t o n e a l c y s t s : a c l i n i c a l s t u d y o f 3 3 n e w c a s e s . A n n S u r g 1973;

1 7 8 : 1 3 - 1 9

4 . G o r d o n M J , S u m e r T E . A b d o m i n a l u l t r a s o n o g r a p h y i n a

m e s e n t e r i c c y s t p r e s e n t i n g a s a s c i t e s . G a s t r o e n t e r o l o g y

1975;69 :761-764

5 . M i t t e l s t a e d t C . U l t r a s o n i c d i a g n o s i s o f o m e n t a l c y s t . R a d i o l -

o g y 1975;117:673-676

6 . H a i l e r J O , S c h n e i d e r M , K a s s n e r E G , e t a l . S o n o g r a p h i c

e v a l u a t i o n o f m e s e n t e r i c a n d o m e n t a l m a s s e s i n c h i l d r e n . A J R

1978;130:269-274

7 . W i c k s J D , S i l v e r T M , B r e e R L . G i a n t c y s t i c a b d o m i n a l

m a s s e s i n c h i l d r e n a n d a d o l e s c e n t s : u l t r a s o n i c d i f f e r e n t i a l d i -

agnos i s . A J R 1978;130:853-857

8 . R i f k i n M D , K u r t z A B , P a s t o M E . M e s e n t e r i c c h y l o u s

( l y m p h - c o n t a i n i n g ) c y s t . G a s t r o i n t e s t R a d i o l 1983:8 :267-269

9 . G e e r L L , M i t t e l s t a e d t C A , S t a a b E V , G a i s i e G . M e s e n t e r i c

c y s t : s o n o g r a p h i c a p p e a r a n c e w i t h C T c o r r e l a t i o n . P e d i a t r

R a d i o l 1984;14 :102-104

1 0. N i c o l e t V , G r i g n o n A , F i l i a t r a u l t D , B o i s v e r t J . S o n o g r a p h i c

a p p e a r a n c e o f a n a b d o m i n a l c y s t i c l y m p h a n g i o m a . J Ultra-

s o u n d M e d 1 9 8 4 ; 3 : 8 5 - 8 6

1 1 . R o s P R , O l m s t e d W W , M o s e r R P J r , e t a l . M e s e n t e r i c a n d

o m e n t a l c y s t s : h i s t o l o g i c c l a s s i f ic a t i o n w i t h i m a g i n g c o r r e l a -

t ion . R a d i o l o g y 1987;164:327-332

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1 3. C a r o p r e s o P R . M e s e n t e r i c c y s t s - - a r e v ie w . A r c h S u r g

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1 4. G r o s s R E , H o l c o m b G W , F a r b e r S . D u p l i c a t i o n c y s t o f t h e

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R e c e i v e d : N o v e m b e r 2 , 1 9 90 ; a c c e p t e d : D e c e m b e r 1 0 , 19 9 0

abdominal imaging volume 16 issue 1 1991 [doi 10.1007_bf01887376] yi -hong chou; chui -mei tiu; wing...

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