Cystic lymphangioma of the mesentery.A 30-year-old man with a four-month history of colicky abdominal pain occurring after meals. He dated the onset of symptoms from 11 September 2001. The pain last about 30 minutes. Recently his symptoms had worsened. There was some nausea, but no other digestive tract symptoms and his general health was good. He had been investigated by endoscopy and colonoscopy - both of which were normal. A CT was performed. This showed a "whirlpool" pattern to the small bowel mesentery, and a diagnosis was made of a midgut volvulus. It was also noted that his bladder was grossly distended. He had no symptoms of urinary obstruction - although as a four-year-old suffered severe injuries when run over by a car, and required several emergency neurosurgical procedures. It was conjectured that the two could have been related.
The first CT radiograph shows the whorled pattern to the mesentery of the small bowel - and the fluid-filled loops of dilated small bowel.
The second CT radiograph shows the cystic mass.
Arrangements were made for a small bowel series, however the patient developed complete intestinal obstruction and went straight to laparotomy. At operation a dilated loop of proximal jejunum was found twisted around a collapsed piece of more distal small bowel. Both pieces of bowel were found to be adherent to what was initially thought to be the bladder. The photograph shows distended and collapsed bowel adherent to this structure. On closer inspection, this large mass occupying all of the pelvis could be delivered into the wound without difficulty.
The small bowel was intimately involved with the superior aspect of the cyst. This is a mesenteric cyst.
The cyst and the attached segment of small bowel were resected. The cyst was thin-walled and full of lymph. The histology confirmed the diagnosis of a cystic lymphangioma of the mesentery.
Comments: lymphangiomatous cysts of the mesentery are rare - and a most unusual cause of small bowel obstruction.
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