by donnie rose torres, md october 3, 2013 icu conference room

Mesenteric and Omental CystIn An Infant

By Donnie Rose Torres, MDOctober 3, 2013

ICU Conference Room

GRAND ROUNDS

Objectives To present an approach to a case of

abdominal distension in an infant

To discuss the approach to diagnosis, incidence, management, complications and prognosis of patients with mesenteric and omental cyst

To present hemangiolymphangioma as a histological finding for mesenteric and omental cyst

Patient’s DataRA DG,

1-month old femalefrom Calbayog, Samar

admitted from AFP Medical Centercoordinated transfer to our institution

last June 29, 2013

Chief Complaint: ABDOMINAL DISTENSION

History of Present Illness

• Born to a 26-year old G1P1 (1001)• non-smoker, non-alcoholic beverage

drinker • w/ PNCU w/ a private obstetrician @

Calbayog, Samar

BMHx

• wanted pregnancy• (-) intake of abortifacients• (+) exposure to Xray radiation

at 1 month of pregnancy• (+) UTI on the 1st trimester

1st trimest

er of pregna

ncy


• 4th and 5th mos of pregnancy - Normal abdominal UTZ and CAS

2nd trimest

er

• 7th mo - abdominal ultrasound revealed ascites, to consider toxic megacolon, to consider mass on the right abdomino-pelvic area

• 8th and 9th mos - right abdomino-pelvic mass

3rd trimest

er


• FT via CS sec to fetal abdominal enlargement

• @ St. Camillus Hospital, Calbayog, Samar

• NMSAF, no cord coil• 40 weeks by BS, APGAR 8,9• BW - 3.8 kg, BL – 47 cm, HC -

34 cm• CC - 33 cm AC – 34 cm• Abdomen not distended at

that time

Upon delive

ry


• Routine NB care rendered• 1st UO and BM w/in 24 hrs of life• discharged with mother on the 3rd day of

life• on direct breastfeeding, with good suck

and activity

1st to 3rd

days of life

• follow-up UTZ: Abdomino-pelvic cystic mass, more on the right vs. massive ascites with septations, Normal liver, gall bladder, spleen, kidneys, urinary bladder and uterus

• Advised to seek consult in Manila

5th DOL


• daily AC monitoring • 10th DOL – 37cm• 15th DOL – 39cm• 20th DOL - 43cm

10-20th DOL

• progressive abdominal distension AFP Medical Center PCMC

• repeat UTZ - showed multi-loculated intraperitoneal fluid collection, subhepatic region down to pelvic cavity, to consider multi-loculated ascites vs ovarian pathology. Non visualized gall bladder, obscured aorta and pancreas.

• Normal ultrasound of the spleen and kidneys

23rd DOL


• Pedia Sx - No indication for surgical intervention that time.

• PCMC AFP Medical Center23rd DOL

• Surgery Service A> nonsurgical abdomen t/c ascites

• Admitted by Pedia service

23rd DOL(AFP Med

Center)


LABS at AFP Med

Center

CBC TPAG Bilirubins

Electrolytes

ABG

Hgb 141.4

TP - 49 TB 10.57 Na 135 pH 7.41

Hct 38

A – 39.1 B1 0.98 K 5.5 pCO2 29

Wbc 5.14 G – 9.9 B2 9.57 Cl 107 HCO3 18

Neu 60 pO2 96

Lym 31 ALT 282 (2.37 x elevated)

Crea <18 O2 sat 97%

Plt 452

AST 35 BE -5.8


• PCMC for Gynecology consult

• trans-abdominal UTZ: Prepubertal uterus, pelvoabdominal mass, ovarian new growth cannot be totally ruled out

• LDH, BHCG (0.15 IU)– Normal

• AFP - >1000 IU/ml• Abdominal CT Scan:

Loculated cyst vs Huge Pelvo-abdominal cystic mass

29th DOL


• patient remained stable, afebrile

• slight jaundice up to chest

• progression of the abdominal distension

• 36th DOL - coordinated transfer to PCMC

• for exploratory laparotomy

• Referred to Gyne, Surgery and Hematology

30-36th DOL

Review Of SystemsGeneral: (-) weight lossSkin: (-) excessive drynessENT: (-) epistaxis, (-) excessive salivation , (-) eye and ear dischargeNeck: (-) limitation of movementRespiratory:

(-) cough, (-) colds, (-) difficulty of breathing

Review Of SystemsGastrointestinal:

(-) vomiting, regular bowel movement, (-) constipation, (-) hematemesis, (-)

melena, (-) hematochezia, (-) acholic stools

Endocrine: (-) polyuria, (-) polydipsia

Genitourinary: (-) discharge, (-) genital rashes, (-)

hematuriaMusculoskeletal:

(-) limitation of movementNervous system:

(-) irritability, (-) changes in activity

Family History

(+) history of DM – paternal side(+) history of Hypertension – maternal side(-) history of Asthma, Malignancy, TB, Renal and Hepatic diseases on both sides

21soldier

26housewife

Immunization History (+) BCG (+) Hepatitis B 1st dose - given upon

birth

Nutritional History Exclusively breastfed

Past Medical History No history of blood transfusion No allergies to drugs

Personal and Social History lives with parents and 3 other

relatives 2-storey, 3-bedroom house owned by their family (-) exposure to smoking (-) exposure to chronic cough use tap water for consumption garbage collected thrice a week

Physical ExaminationGeneral Survey: awake, not irritable, activeVital signs:

BP: 80/50 Wt: 5.6 kgs (z score 2) BSA: 0.28CR: 130 bpm Lt: 53 cm (z score 0)RR 34 cpm HC: 38 cm (z score 0) T: 36.7 oC CC: 35 cm

AC: 44cm umbilical level, 46cm widest diameterSkin: jaundice from face to chest, warm, moist skinHEENT: open and flat anterior and posterior fontanelles, no molding, (+) erythematous maculopapular rashes on the face, anicteric sclerae, nonsunken eyeballs, pink palpebral conjunctiva, no

nasoaural deformities and discharges, moist lips, no cleft lip, no cleft palate, no neck masses, no cervical lymphadenopathies

Physical ExaminationChest and lungs:

no gross chest deformities, symmetric chest expansion, good air entry, clear breath

sounds, no retractions

Cardiovascular:adynamic precordium, no heaves nor thrills,

regular rate and rhythm, distinct heart sounds, apex beat at 4th intercostals space mid-axillary line, no murmursGenitalia: grossly female-looking genitaliaAnus: patent anal openingSpine: straight spinal column, no spinal masses, no sacral dimpling, no tufts of hairExtremities: no polydactyly, no other deformities, no edema, full and equal pulses, good capillary refill time

Physical ExaminationAbdomen: distended, AC – 44

cm umbilical level, 46 cm widest diameter

(+) prominent abdominal veins

normoactive bowel sounds

Tympanitic soft (-) hepato-

splenomegaly, (+) 5 x 6 cm, solid,

ill-defined mass palpated midline

Neurologic Examinationawake, active CN I: not assessedCN II: (+) dazzleCN II , III: pupils 2-3 mm equally reactive to light CN III, IV, VI: full and equal EOM CN V: not assessedCN VII: no facial asymmetry CN VIII: not assessedCN IX, X: good gag reflex CN XI: not assessedCN XII: tongue at the midline, no fasciculationMotor: Normal muscle bulk; Normal muscle tone; No fasciculationSensory: withdraws to pain stimuli

(+) Babinski, bilateral, No clonus Signs of Meningeal Irritation: (-) nuchal rigidity, Brudzinski sign: negative, Kernig sign: negative Reflexes: (+) rooting, palmar, Moro

Salient Features1 month old

FemaleProgressive abdominal distension

In Utero:* (+) exposure with Xray radiation* Ascites v R abdominopelvic mass at 7 to 9th mos on UTZ

On abd CT Scan and ff up UTZ:

T/C loculated ascites vs

Huge Pelvo-abdominal cystic

massPhysical

Examination:* Jaundiced up to chest* Abdomen distended* Visible veins* (-) hepatosplenomegaly* 5 x 6 cm solid ill-defined mass palpated midline

Labs: * increased AFP* increased ALT* Normal BHCG * Normal LDH

Salient Features1 month old

FemaleProgressive abdominal disension

In Utero:* (+) exposure with Xray radiation*Ascites v R abdominopelvic mass at 7 to 9th mos on UTZ

On abd CT Scan and ff up UTZ:

T/C loculated ascites vs

Huge Pelvo-abdominal cystic

massPhysical

Examination:* Jaundiced up to chest* Abdomen distended* Visible veins* (-) hepatosplenomegaly* 5 x 6 cm solid ill-defined mass palpated midline

Labs: * increased AFP* increased ALT* Normal BHCG * Normal LDH

Working DiagnosisAscites vs Pelvo-abdominal Mass, Pobably:1. Ovarian cyst2. Germ cell tumor3. Mesenteric and Omental cystNo wasting, no stunting

Approach to the Diagnosis

ASCITES

hepatic

renal

cardiac

Abdominal distension

tumorsPregnancy/obesity


OLDER CHILDRE

N ASCITES

trauma

infection

Hepatocellular disease

miscellaneous

neoplasia

Gynecologic or GIT abN


NEONATAL

ASCITES

biliary

urinary

chylous

Spontaneous perforation of the bile

ductPerforation of choledocal cyst

Complex urinary anomaliesPerforation of bladder or ureteral tract

Idiopathic

Congenital lymphatic Abn

External compression of lymphatics

HerniaIntususceptionNeoplasm


NEONATAL

ASCITES

biliary

urinary

chylous

Pertinent + Age group (< 3

months) Mild jaundice Abdominal distension

Pertinent -• Feeding intolerance• Rare• Direct

hyperbilirubinemia• UTZ findingsPertinent +

Abdominal distension

Pertinent -• Male predominance• Prenatal UTZ• oligohyramnios• Metabolic acidosis• Elevated BUN/Crea• Electrolyte ABN

Pertinent + Congenital Abdominal distension UTZ and CT Scan

findings

Pertinent -• Feeding intolerance• Male predominance

MiscellaneousCardiacInfection


CHYLOUS

ASCITES Congenital lymphatic Abn

External compression of

lymphatics

Idiopathic

Hernia

Intususception

Tumors/Neoplasm

Germ cell tumors

Ovarian Mass

hepatoblastoma

Mesenteric/Omental Cyst

Assessment of Abdominal Mass Ch 78, by RH Sills Practical Algorithms in Hematology and Oncology

Assessment of a Pelvic Mass Ch 80, by RH Sills Practical Algorithms in Hematology and Oncology

Course In the WardsCBC 6/29Hgb 125.5Hct 0.38Platelet count 478wbc 4.9Basophils 0.01Eosinophils 0.07Neutrophils 0.25Lymphocytes 0.52Monocytes 0.15

1st Hosp day Jaundice Distended abdomen Prominent veins Soft No organomegaly Ill defined mass The rest of PE and

Neuro exam NORMAL

LABS

Electrolytes 6/29

Na 135K 4.8Cl 108Ca 2.65P 2.09Uric acid 201Total prot 50.5albumin 31globulin 19.5A/G ratio 1.6

LDH 934AFP 8486 IU/mlAST 43ALT 28Bilirubins

TB 5.6 DB 0.8 IB 4.7

Course In the Wards1st

Hosp day

JAUNDICELDH

BHCGAFP

TUMOR MARKERS

Heplock DBF Gyne, Hema and

Surgery

HEMA:A> Pelvo-abdominal Mass prob ovarian in origin, r/o GCT Hydration Aluminum Hydroxide Monitoring of Tumor MarkersGYNE/SURG:A> Pelvo-abdominal Mass prob ONG Ex-Lap

Course In the Wards2nd

Hosp day

WARDS Gr 2/6 HS

murmur 2nd ICS LPSB

IVF mtn rate

2 d echo: PFO Hyperkalemia

HypercalcemiaSalbutamol

nebIVF mtn rateRpt LABS

Normokalemia Hypercalcemia Normal U/A Uncompensated Metabolic

acidosis A> T/C Tumor Lysis

Syndrome, Hypercalcemia of Malignancy

Hydration 2L/BSA

Electrolytes

6/30

Na 141K 4.4Cl 115Ca 2.6

8

ElectrolytesNa 137K 5.6Cl 108Ca 2.75

VBG 6/30pH 7.26pCO2 26HCO3 11.7BE -13.8pO2 47O2 sat 75%


Hosp day

Hyperkalemia Hyperphosphatem

ia Hyperuricemia Hyperuricosuria Hypocalcemia Lactic acidosis

TUMOR LYSIS SYNDROME

Cairo-Bishop definition

Clinical TLS

Laboratory TLS

Vs Pre-treatment spontaneous TLS

Treatment Targeted to specific metabolic disorder Hyperkalemia – pushes K back

intracellularly Hyperphosphatemia – hydration,

AlOH Acidosis – Hydration, NaHCO3


Hosp day

HYPERCALCEMIA

OF MALIGNANCY

Treatment Targeted to underlying cause Hydration – decreased Ca through

dilution, incraeses renal Ca clearance Forced diuresis – increased Ca

excretion, avoid volume overload, increase Ca reabsorption

Bisphophonates – inhibit osteoclast activity

Course In the Wards6th to 9th Hosp day

Pre-op Conference

Pre-op LabsPT 7/7/

13patient 10.8

0control 11.3activity 100

INR 0.95PTT patient 35.8control 28.1

Electrolytes

7/7

Na 135K 4Cl 109Ca 2.55P 1.78Uric acid 240

Course In the Wards10th Hosp

day

Exploratory Laparotomy

Intra-op findings: 5 x 7 cm omental

cyst with chylous contents

Milky ascites

Intra-op findings: Mesenteric cyst

occupying almost all of the small intestine mesentery extending to the retroperitoneal space

Marsupialization of the mesenteric cyst

Working DiagnosisMesenteric and Omental Cyst

S/P Excision of Cyst and Marsupialization of Mesenteric

Cyst (7/8/13), Chylous ascites

No wasting, No stunting

Mesenteric and Omental Cyst

History 1507: Benevieni while performing an

autopsy descibed the mesenteric cyst on an 8-year-old boy

1842: Rokitansky recorded the first description of a chylous cyst

1852: Gairdner published the first report of an omental cyst

1880: Tillaux performed the first successful surgery for a cystic mass in the mesentery

Kurtz, RJ et al. (Jan 2010). Mesenteric and retroperitoneal cyst. Annals of Surgery. Ann Surgery 203:109-112

Epidemiology Mesenteric and omental cysts are rare.

Incidence: 1 per 140,000 general hospital admissions

1 per 20,000 pediatric hospital admissions

In a study from Egleston Children's Hospital at Emory University from 1965-1994, 14 patients were treated for mesenteric or omental cysts, which represents a prevalence of about 1 case per 11,250 admissions.

1/3 of cases: occur in children < 15 years old

Mean age of children: 4.9 years old

Mesenteric cysts > omental cysts(4.5x more)

Epidemiology“…48% were females. The mean age was 25 years, with a range from 1 day to 83 years.”


“17 (age less than 10 years) with mesenteric cysts were managed in the hospital. The age ranged from 15 days to 10 years.”

Prakash A. et al (Sep – Dec 2010). Early management of mesenteric cyst prevents catastrophes: a single centre analysis of 17 cases. Afr J Paediatr Surg 2010 7(3):140-3

Epidemiology“ There were nine females out of 16 (56%) and seven males (44%), with age range of 12-68 years old.”

Tan JJ, et al. (Sep 2009). Mesenteric cysts: an institution experience over\ 14 years and review of literature.World J Surg 33(9):1961-5

“The age ranged from 6 months to 68 years old with a mean of 22. Five of the patients were 10 years old or younger.”


EtiologyProposed theories:

Gross: “…mesenteric and omental cysts are thought to represent benign proliferations of ectopic lymphatics that lack communication with the normal lymphatic system.”

“Cysts are thought to arise from lymphatic spaces associated with the embryonic retroperitoneal lymph sac, making them analogous to cystic hygromas which arise in the neck in association with the jugular lymph sac.”

Egozi EI, Ricketts RR. Mesenteric and omental cysts in children. Am Surg. Mar 1997;63(3):287-90 Bliss DP Jr, Coffin CM, Bower RJ, et al. Mesenteric cysts in children. Surgery. May 1994;115(5):571-7.

EtiologyProposed theories: lymphatic obstruction

however, experimental occlusion of lymphatic channels in animals does not produce mesenteric or omental cysts because of the rich collaterals in the lymphatic system, which sheds doubt on this particular theory.[

Other etiologic theories include failure of the embryonic lymph channels to join the

venous system failure of the leaves of the mesentery to fuse trauma neoplasia degeneration of lymph nodes

Takiff H, Calabria R, Yin L, Stabile BE. Mesenteric cysts and intra-abdominal cystic lymphangiomas. Arch Surg. Nov 1985;120(11):1266-9.

Vanek VW, Phillips AK. Retroperitoneal, mesenteric, and omental cysts. Arch Surg. Jul 1984;119(7):838-42. Egozi EI, Ricketts RR. Mesenteric and omental cysts in children. Am Surg. Mar 1997;63(3):287-90.

IncidencePPS

PCMC

Clinical Presentation incidental finding during laparotomy present with abdominal distention and few

associated symptoms other than vague abdominal pain with or without a palpable mass

mass may be huge, simulating ascites acute presentation in children is that of a small-

bowel obstruction, which may be associated with intestinal volvulus or infarction

These masses can be detected using prenatal UTZ appear as a sonolucent

Ricketts RR. Mesenteric and omental cysts. In: Pediatric Surgery. 5th ed. 1998:1269-75.

Clinical Presentation Analysis of the younger patients in this series

shows that they have shorter duration of symptoms and are more likely to present as surgical emergencies.

Although the average size and volume are identical for adults, they were fewer retroperitoneal cysts in the younger age group. This resulted in a higher resectability and a significant lower recurrence.


Clinical Presentation “In a series of 82 children who underwent surgery

for various causes of intestinal volvulus, mesenteric cysts were the underlying etiology in 3.65% of cases.”

Maung M, Saing H. Intestinal volvulus: an experience in a developing country. J Pediatr Surg. May 1995;30(5):679-81.

A very unusual presentation of a mesenteric cyst is that of an irreducible inguinal hernia.

Mohanty SK, Bal RK, Maudar KK. Mesenteric cyst--an unusual presentation. J Pediatr Surg. May 1998;33(5):792-3.

Diagnostics Plain radiographs Abdominal Ultrasound CT Scan of the

abdomen Radionuclide scan of

biliary tract CT Scan with

angiography

Diagnostics Diagnostic includes abdominal computed

tomography, ultrasound and MRI. Barium enema examination or intravenous

pyelogram may be used in special cases. Casarroto, A. et al (May 31 2010). Mesenteric cyst: case report and review of the literature. G Chir.

2010 (5):239-42

USG was not conclusive in all. Abdominal CT scan with intravenous contrast

was diagnostic in nine patients. Five patients had volvulus on exploration.

Prakash A. et al (Sep – Dec 2010). Early management of mesenteric cyst prevents catastrophes: a single centre analysis of 17 cases. Afr J Paediatr Surg 2010 7(3):140-3

Gross Findings

Vanek VW, Phillips AK. Retroperitoneal, mesenteric, and omental cysts. Arch Surg. Jul 1984;119(7):838-42. Mollitt DL, Ballantine TV, Grosfeld JL. Mesenteric cysts in infancy and childhood. Surg Gynecol Obstet. Aug

1978;147(2):182-4.

“…occur anywhere in the mesentery of the gastrointestinal tract from the duodenum to the rectum, and they may extend from the base of the mesentery into the retroperitoneum.”

In a series of 162 patients: 60% : small-bowel mesentery 24% in the large-bowel mesentery 14.5% in the retroperitoneum They most commonly occur in the ileal mesentery of

the small bowel or the sigmoid mesentery of the colon.

Omental cysts are confined to the lesser or greater omentum.

Gross Findings There were 23/162 (14%) patients with

retroperitoneal cysts and 139/162 (86%) with mesenteric cysts.


Cysts were located in small intestinal mesentery in 14 cases and 3 were in the sigmoid mesentery. Prakash A. et al (Sep – Dec 2010). Early management of mesenteric cyst prevents catastrophes: a single

centre analysis of 17 cases. Afr J Paediatr Surg 2010 7(3):140-3 The cyst was located in the small bowel mesentery

in 91 patients (60%), in the large bowel mesentery in 37 (24%) and in the retroperitoneum in 23 (4.5%)

In 11 cases, the location was not described.Kurtz, RJ et al. (Jan 2010). Mesenteric and retroperitoneal cyst. Annals of Surgery. Ann Surgery 203:109-112

Gross Findings They ranged in size in the 8 patients in whom this

information is known from 4 to 36 cm in diameter.

The estimated volume of the cysts ranged in these patients from 11 to 5600 cc.


Gross Findings

•Vanek VW, Phillips AK. Retroperitoneal, mesenteric, and omental cysts. Arch Surg. Jul 1984;119(7):838-42. •Mollitt DL, Ballantine TV, Grosfeld JL. Mesenteric cysts in infancy and childhood. Surg Gynecol Obstet. Aug

1978;147(2):182-4.

Histologic Findings “Histologically, all were lymphangiomatous

mesenteric cysts.”Prakash A. et al (Sep – Dec 2010). Early management of mesenteric cyst prevents catastrophes: a single centre analysis of 17 cases. Afr J Paediatr Surg 2010 7(3):140-3

None of the cysts were malignant. Kurtz, RJ et al. (Jan 2010). Mesenteric and retroperitoneal cyst. Annals of Surgery. Ann Surgery 203:109-112

Histologic Findings Although most of the cysts were benign, three

had foci of malignancy and another had a focus of gastrointestinal stromal tumor.

None of the cases recurred during follow-up.

Tan JJ, et al. (Sep 2009). Mesenteric cysts: an institution experience over 14 years and review of literature.World J Surg 33(9):1961-5

Differentials intestinal duplication cyst Ovarian cyst choledochal, pancreatic, splenic, or renal cysts Hydronephrosis cystic teratoma hydatid cyst Ascites


“differential diagnosis: lymphangiomas, sarcomas, adenocarcinomas and intestinal duplications should be considered.”

Casarroto, A. et al (May 31 2010). Mesenteric cyst: case report and review of the literature. G Chir. 2010 (5):239-42

Surgery In children, the most common indication for

surgical intervention is the presence of an abdominal mass with or without signs of intestinal obstruction. The surgical treatment of choice for retroperitoneal and

mesenteric cysts is complete enucleation. If this could not be accomplished, the next best

alternative would be excision of the cyst with, if necessary, the resection of a portion of the adherent bowel.

The last acceptable choice is the marsupialization of the cyst.

Partial excision or simple drainage of the cyst usually results to recurrence.


Surgery Surgical treatment is indicated also in

asymptomatic patients; laparoscopic approach is the "gold standard".

Laparotomic approach should be used in the cases of impossibility of total enucleation or in the cases of malignant degeneration.

Casarroto, A. et al (May 31 2010). Mesenteric cyst: case report and review of the literature. G Chir. 2010 (5):239-42

Surgery A simultaneous intestinal resection was performed

in 56 of the 134 patients in whom this information is known. In 37 cases, a resection of the small intestine was

performed. In 3 cases, a right hemicolectomy was necessary with an

ileotransverse anastomosis. There was 1 case each for mesenteric and retroperitoneal

cyst requiring resection of the sigmoid colon. Kurtz, RJ et al. (Jan 2010). Mesenteric and retroperitoneal cyst. Annals of Surgery. Ann Surgery

203:109-112

Laparoscopic surgical excision of the cyst was performed in 3 (19%) patients, laparotomy in 12 (75%), and 1 patient refused surgery.

Tan JJ, et al. (Sep 2009). Mesenteric cysts: an institution experience over 14 years and review of literature.World J Surg 33(9):1961-5

Correct Diagnosis Diagnosis was proven in all cases of Laparotomy. The correct pre-operative diagnosis was made in

only 3 cases out of 162 and 2 of these were patients with retroperitoneal cysts.


The correct pre-operative diagnosis was made in 30 out of 122 patients (25%) in whom this information is know, 45% were operated as emergencies.


Course in the wards10th HD

Intra-op: had 1 hypotensive episode, BP 60/40 while draining 400 cc chyle from omental cyst and from peritoneal cavity

EBL: 20cc

Admitted at ICU for post-op careLABS

CBC 7/08Hgb 100Hct 0.29Platelet count

639

wbc 6.5Basophils 0.01Eosinophils Neutrophils 0.80Lymphocytes

0.14

Monocytes 0.05

CBC 7/09Hgb 128Hct 0.37Platelet count

568

wbc 3.5Basophils Eosinophils 0.01Neutrophils 0.24Lymphocytes

0.61

Monocytes 0.14

ABG 7/8pH 7.3

3pCO2 27HCO3 14.

2BE -

10.2

pO2 123O2 sat 99

%

PT 7/8/13

patient 10.90control 11.3activity 100

INR 0.96PTT

patient 35control 27

Electrolytes

7/8

Na 133K 4.2Cl 111Ca 2.32Total prot 42.30albumin 23.70globulin 18.70A/G ratio 1.30Creatinine 34BUN 0.90


NPO OGT was kept open CBG monitoring Omeprazole IV IVF hydration – 2L/BSA Cefuroxime – post-op

antibiotics Pain management


Minimal OGT output Clamped

Serous output on the post-op site

Abdomen nondistended, soft, nontender

Trans-out to Surgery wards

Maintained on NPO Hydration and meds

continued

Course in the wards12 to 14th

HD

Problems: Edematous Hypoglycemia Anemia Decreased

leukocyte hypoalbuminem

ia

CBC 7/12Hgb 107.7Hct 0.32Platelet count

402

wbc 3.5Basophils 0.02Eosinophils 0.08Neutrophils 0.22Lymphocytes 0.56Monocytes 0.12

45.90

28.00

17.80

1.60

Total prot 42.20

albumin 23.80

globulin 18.50

A/G ratio 1.30

IVF decreased to maintenance rate

Cefuroxime increased to 150mkday

Trial feeding Minimal milky, serous

output from the drain

Course in the wards15th to 17th

HD Decreased milky output from

post-op site Referred to GI: dietary

specifications

CHYLOUS ASCITES

treatmentGI service: Resume DBF Shift IVF to HL D/C Omeprazole

Treat the underlying cause. Repeated paracentesisDiuretic therapy

Salt and water restriction

Dietary measures

“low-fat diet with medium-chain triglyceride supplementation can reduce the flow of chyle into

the lymphatics.”Weinstein LD, Scanlon GT, Hersh T. Chylous ascites. Management with medium-chain triglycerides and exacerbation by lymphangiography.

Am J Dig Dis. Jul 1969;14(7):500-9.

Bowel rest and TPN

Albumin and pRBC transfusion

Role of octreotide??“Multiple case reports describe the use of octreotide, a somatostatin analog, in the management of chylous ascites,

typically at a dose of 100 mcg administered subcutaneously 3 times per day.”

Yilmaz M, Akbulut S, Isik B, Ara C, Ozdemir F, Aydin C, et al. Chylous ascites after liver transplantation: incidence and risk factors. Liver Transpl. Sep 2012;18(9):1046-52.

“A combination of total parenteral nutrition and subcutaneous octreotide has been used to successfully treat

congenital chylous ascites in a newborn.”Olivieri C, Nanni L, Masini L, Pintus C. Successful management of congenital chylous ascites with early

octreotide and total parenteral nutrition in a newborn. BMJ Case Rep. Sep 25 2012;2012

Course in the wards17th – 19th

HD Rpt LDH: 678 Rpt AFP: 8486 1467

IU/ml

Cefuroxime x 7 days – d/c 1cc output from the drain

removed Multivitamins and Zinc Transferred to AFPMC

Complications “Various complications …., including intestinal

obstruction (most common), volvulus, hemorrhage into the cyst, infection, rupture, cystic torsion, and obstruction of the urinary and biliary tract.


Complications are rare: rupture, infection and intestinal obstruction.

Pisano, G. et al (Aug 2004). Acute abdomen due to rupture of mesenteric cysts. Observations on a clinical case and review of the literature. Minerva Chir. 59(4):405-11.

Prognosis Malignant transformation of mesenteric cysts has

occurred in adults, but malignant mesenteric and omental cysts have not been reported in children


Only 1 patient developed a recurrence of the cyst and required second operation.

This patient had retroperitoneal cyst which was partially excised at the 1st operation.

She is doing well 7 years after marsupialization of the cyst, despite the persistent drainage of fluid.


Prognosis 5 out of 162 (3%) patients were found to have

malignant cysts. 10 cysts recurred, requiring 2nd operation. 5 of

these recurrences in the 23 patients (22%) whose cysts are retroperitoneal in location (p<0.001).

All cancers were found in adult patients. There were 3 deaths out of 162 (1.9%). 1 death reported in retroperitoneal cysts.


Recurrence There is a statistically significant correlation

between the recurrence of the cyst and location. 5/10 recurrences (50%) occurred in retroperitoneal

cysts. There is no correlation between age, duration of

symptom, diameter or volume of cyst and to RECURRENCE.


Retroperitoneal cysts are technically more difficult to excise completely because of their proximity to blood vessels and other organs, and therefore a RECURRENCE is more likely.


Tissue Diagnosis Impression:

HemangiolymphangiomaHistologic sections of omentum and mesenteric portions show several, small vascular channels and lymphatic spaces set in fibrocollagenous

stroma that contain occasional lymphoid aggregation.

No atypia nor malignancy seen.

Histologic Findings

Cystic lymphangiomas vs mesenteric and omental cysts

Cystic lymphangiomas: have an endothelial cell lining, foam cells, and thin walls that contain lymphatic spaces, lymphoid tissue, and smooth muscle.

Mesenteric cysts: lack smooth muscle and lymphatic spaces, and the cells lining the cysts are cuboidal or columnar in nature

Takiff H, Calabria R, Yin L, Stabile BE. Mesenteric cysts and intra-abdominal cystic lymphangiomas. Arch Surg. Nov 1985;120(11):1266-9.

Bliss DP Jr, Coffin CM, Bower RJ, et al. Mesenteric cysts in children. Surgery. May 1994;115(5):571-7.

Histologic Findings

Lymphangiomas are more diffuse and occur in the mesentery or retroperitoneum, and patients may present earlier in life than those with mesenteric or omental cysts.

In a series of 191 patients with lymphangioma, 4.7% of patients presented with lymphangioma in the mesentery.

Alqahtani A, Nguyen LT, Flageole H, Shaw K, Laberge JM. 25 years' experience with lymphangiomas in children.

J Pediatr Surg. Jul 1999;34(7):1164-8

An omental cyst has the same histologic characteristics but is confined to the greater or lesser omentum

HemangiolymphangiomaLymphangiomas : malformations of the lymphatic system, which is the network of vessels responsible for returning to the venous system excess fluid from tissues

These malformations can occur at any age and may involve any part of the body, but 90% occur in children less than 2 years of age and involve the head and neck.

These malformations are either congenital or acquired.

Congenital lymphangiomas: Turner syndrome, isolated case.

Acquired lymphangiomas: trauma, inflammation, or lymphatic obstruction

Hemangiolymphangioma soft, slow-growing, "doughy" mass. lymphangiomas are usually treated for

cosmetic reasons only

Complications: such as respiratory distress when a lymphangioma compresses the airway

Treatment: aspiration, surgical excision, laser and radiofrequency ablation and sclerotherapy

Hemangiolymphangioma 3 subtypes: Capillary, Cavernous and

Cystic Lymphangioma

based on their microscopic characteristics

A fourth subtype, the hemangiolymphangioma is also recognized.

Capillary lymphangiomas Cavernous lymphangiomas Cystic hygromas Hemangiolymphangioma

Review of literatureINTRODUCTION:

“…..There are several classifications of these formations, among which the one based on histopathologic features including 6 groups has been most commonly used: 1) cysts of lymphatic origin--lymphatic (hilar cysts) and lymphangiomas; 2) cysts of mesothelial origin--benign or malignant mesothelial cysts; 3) enteric cysts; 4) cysts of urogenital origin; 5) dermoid cysts; and 6) pseudocysts--infectious or traumatic etiology.”

Kirurski, O. et al. (2002) Mesenteric cysts. Acta Med Croatica 56(3):119-24.

Review of literaturePATIENTS AND METHODS:

Two adult female patients treated at the Department of Surgery, Zabok General Hospital, are presented.

The diagnosis of mesenteric cyst was based on explorative laparotomy indicated for a cystic abdominal growth and characteristic palpatory finding, US and CT findings.

In both patients, the cysts were successfully treated by total cystectomy.

Histopathologic findings pointed to lymphatic cysts.

Control US finding at 3 months postoperatively was normal in both patients.


Review of literatureDISCUSSION:

Cystic lymphangioma mostly occurs in the first decade of life, with a female predominance.

It is usually accompanied by acute abdominal symptomatology. • Lymphatic cysts occur later in life (1:100,000 in adults and

1:20,000 in children), also show female predominance, and as a rule are asymptomatic.

A mesenteric cyst, especially lymphatic, should be suspected in the presence of painless abdominal tumor, with occasionally painful abdominal pressure, normal laboratory findings, and good general condition in a female patient.



cystic mesenteric tumor is mostly used to refer to cystic lymphangiomas and lymphatic cysts

Cystic lymphangiomas: smooth muscle tissue is found, with endothelial lining towards the cavity.

The wall of hilar mesenteric cysts does not contain smooth muscle tissue, however, they also show endothelial lining towards the cavity.

Exact differentiation between these two entities is necessary for the disease prognosis.



Lymphangiomas are prone to recurrence and infiltrating growth.

The diagnosis should be made by use of all standard methods of abdominal tumor diagnosis, with ultrasonography (US) and computed tomography (CT), and especially nuclear magnetic resonance providing most information of the growth size and localization.

Total cystectomy is the therapeutic method of choice. Open method has been preferred, although reports on

successful cystectomy by the laparoscopic method have already appeared in the literature.


Review of literatureCONCLUSION:

• Intraoperative differentiation between lymphatic cyst and lymphangioma is of utmost importance, and can only be achieved by histopathologic examination of the cyst wall.

• If intraoperative biopsy cannot be performed or the finding is uncertain, each cyst should be extirpated in toto due to the above mentioned risk associated with cystic lymphangioma.


Pre-natal Surveillance With the widespread use of prenatal

ultrasonography, mesenteric and omental cysts are being diagnosed in utero.

No role for treating these cysts in utero is recognized.

If cysts are discovered prenatally, intervention during early infancy is indicated to prevent potential complications such as obstruction and intestinal volvulus.


Final DiagnosisMesenteric and Omental Cyst (Hemangiolymphangioma)

S/P Excision of Cyst and Marsupialization of Mesenteric

Cyst (7/8/13), Chylous ascites, resolvedNo wasting, No stunting

Summary 1-month old female from Samar Diagnosed in utero with ascites vs right

pelvoabdominal cystic mass confirmed by ff up UTZ and CT scan during neonatal period

Tumor markers were monitored On X-lap, has mesenteric and omental

cyst with chylous ascites Underwent excision and

marsupialization of respective cysts Tissue biopsy of

Hemangiolymphangioma

Update

Thank you and Good day!

by donnie rose torres, md october 3, 2013 icu conference room

Documents

present hemangiolymphangioma

abdominal circumference

illdefined mass

case of abdominal distension

emergency room

note of jaundice

omental cystin

good condition