Pediatric abdominal chylolymphatic cysts
Abstract
Although mesenteric cysts in general have been reported in the literature fairly frequently,
chylolymphatic cysts in the pediatric age group are extremely rare in the modern medical literature.
Ultrasonography and computed tomography suggest the diagnosis but the picture is not clear
until demonstrated intraoperatively. Intra-operatively, similar findings can be seen in cystic
lymphangioma, retroperitoneal cystic teratoma, caseating tubercular lymph nodes, and hydatid
cysts. Even lymphoma and duplication cysts may also give similar appearances. Excision biopsy is
then recommended to differentiate these cases. Histopathology is confirmatory and differentiates
chylolymphatic cysts from all these lesions. We present our experience with two such cases that
presented to our center.
Keywords: Chylolymphatic; Mesenteric cyst; Ileum; Abdominal pain
Introduction
A chylolymphatic cyst is a rare variant of a mesenteric cyst [1,2]. These cysts present within the
mesentery, lined with a thin endothelium or mesothelium and filled with chylous and lymphatic
fluid [3]. Although mesenteric cysts in general have been reported in the literature fairly frequently,
chylolymphatic cysts in the pediatric age group are extremely rare in the modern medical literature
[2], therefore very little information is available regarding their presentation which can vary from
asymptomatic to an acute abdomen with intestinal obstruction. Ultrasonography and computed
tomography can provide an idea regarding the diagnosis but the intraoperative findings are often
quite different. Histopathological examination of the specimen is required for confirmation.
Complete excision of the cyst yields excellent result. In an attempt to reinforce the diagnostic and
treatment strategy, we present our experience with two such cases that presented to our center
within a short span of two weeks.
Case Presentation
Case 1
A 4 years old female child presented with abdominal pain of 6 months duration. The pain
was dull, aching and continuous in nature. It was associated with mild abdominal distension
noted for the last 1 month. The general physical examination was unremarkable. The abdomen
was mildly distended but soft and suggestive of diffuse ascites rather than a discrete palpable mass.
An ultrasonography (USG) and computed tomography scan (CT scan) of the abdomen revealed a
large, septated, cystic mass with hypodense fluid attenuation. The biochemical parameters including
serum amylase and lipase were within normal limits. With a preoperative suspicion of mesenteric
cyst or pelvic cyst, the patient was posted electively for exploratory laparotomy but had to be taken
up in the emergency because of a 10 days history of increasing abdominal pain and decreased oral
intake. There was no history of vomiting or constipation.
Upon surgical exploration, there was a
huge cystic mass about 15cm by 18cm in dimension, filled with white milky fluid suggestive of a
chylolymphatic cyst, occupying the mesentery of proximal ileum (Figure 1). The cyst was enucleated
from the mesentery and excised completely along with 5cm of ileum closely related to it (Figure
2). An ileoileal end to end anastomosis was done. Feeds were started from 5th postoperative day
and the patient was discharged on 7th postoperative day without any postoperative complications.
The histopathological examination of resected specimen confirmed the diagnosis of chylolymphatic
mesenteric cyst. At 6 months of follow up the patient is feeding adequately and doing well.
Although mesenteric cysts in general have been reported in the literature fairly frequently,
chylolymphatic cysts in the pediatric age group are extremely rare in the modern medical literature.
Ultrasonography and computed tomography suggest the diagnosis but the picture is not clear
until demonstrated intraoperatively. Intra-operatively, similar findings can be seen in cystic
lymphangioma, retroperitoneal cystic teratoma, caseating tubercular lymph nodes, and hydatid
cysts. Even lymphoma and duplication cysts may also give similar appearances. Excision biopsy is
then recommended to differentiate these cases. Histopathology is confirmatory and differentiates
chylolymphatic cysts from all these lesions. We present our experience with two such cases that
presented to our center.
Keywords: Chylolymphatic; Mesenteric cyst; Ileum; Abdominal pain
Introduction
A chylolymphatic cyst is a rare variant of a mesenteric cyst [1,2]. These cysts present within the
mesentery, lined with a thin endothelium or mesothelium and filled with chylous and lymphatic
fluid [3]. Although mesenteric cysts in general have been reported in the literature fairly frequently,
chylolymphatic cysts in the pediatric age group are extremely rare in the modern medical literature
[2], therefore very little information is available regarding their presentation which can vary from
asymptomatic to an acute abdomen with intestinal obstruction. Ultrasonography and computed
tomography can provide an idea regarding the diagnosis but the intraoperative findings are often
quite different. Histopathological examination of the specimen is required for confirmation.
Complete excision of the cyst yields excellent result. In an attempt to reinforce the diagnostic and
treatment strategy, we present our experience with two such cases that presented to our center
within a short span of two weeks.
Case Presentation
Case 1
A 4 years old female child presented with abdominal pain of 6 months duration. The pain
was dull, aching and continuous in nature. It was associated with mild abdominal distension
noted for the last 1 month. The general physical examination was unremarkable. The abdomen
was mildly distended but soft and suggestive of diffuse ascites rather than a discrete palpable mass.
An ultrasonography (USG) and computed tomography scan (CT scan) of the abdomen revealed a
large, septated, cystic mass with hypodense fluid attenuation. The biochemical parameters including
serum amylase and lipase were within normal limits. With a preoperative suspicion of mesenteric
cyst or pelvic cyst, the patient was posted electively for exploratory laparotomy but had to be taken
up in the emergency because of a 10 days history of increasing abdominal pain and decreased oral
intake. There was no history of vomiting or constipation.
Upon surgical exploration, there was a
huge cystic mass about 15cm by 18cm in dimension, filled with white milky fluid suggestive of a
chylolymphatic cyst, occupying the mesentery of proximal ileum (Figure 1). The cyst was enucleated
from the mesentery and excised completely along with 5cm of ileum closely related to it (Figure
2). An ileoileal end to end anastomosis was done. Feeds were started from 5th postoperative day
and the patient was discharged on 7th postoperative day without any postoperative complications.
The histopathological examination of resected specimen confirmed the diagnosis of chylolymphatic
mesenteric cyst. At 6 months of follow up the patient is feeding adequately and doing well.
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