CASE REPORT Annals of Gastroenterology (2011) 24, 137-139

A ruptured infected mesenteric cyst diagnosed on

laparoscopy for suspected appendicitis

Stephen T. Warda, Baljinder Singhb, Terence J. Jonesb, Charles S. Robertsonb

a
Queen Elizabeth Hospital, UK, bWorcestershire Royal Hospital, UK

Abstract Lower abdominal pain of acute onset in young women with a negative pregnancy test is a
frequent reason for referral to the general surgical team and the differential diagnoses include
acute appendicitis, complicated ovarian cysts and pelvic inflammatory disease. Intestinal and
mesenteric cystic disease is a rare entity and less than half of cases present acutely. We present a
case of a 25-year-old woman who underwent diagnostic laparoscopy for acute lower abdominal
pain and was diagnosed with a ruptured, infected mesenteric cyst.
Keywords laparoscopy, mesenteric cyst, appendicitis, abdomen, acute, general surgery
Ann Gastroenterol 2011; 24 (2): 137-139

Introduction cycle. She was otherwise fit and well with no previous medi-
cal history and on no regular medications. She did admit to
Lower abdominal pain of acute onset in young women a diarrheal illness one month previously during which an
with a negative pregnancy test is a frequent reason for referral out-patient stool culture had grown Campylobacter jejuni.
to the general surgical team and the differential diagnoses On examination, she was noted to be tachycardic with a
include acute appendicitis, complicated ovarian cysts and heart rate of 110 beats per minute and fever at 38.0°C. She
pelvic inflammatory disease. was tender throughout the lower abdomen, mostly in the
Intestinal and mesenteric cystic disease is a rare entity suprapubic area with guarding. Urinalysis was negative for
and less than half of cases present acutely. We present a case blood, nitrites and leukocytes and a urinary pregnancy test
of a young woman who underwent diagnostic laparoscopy was negative. Her blood investigations revealed a raised white
for acute lower abdominal pain and was diagnosed with a cell count of 19.1 (normal range 4 – 11 109/L) and a C-reactive
ruptured, infected mesenteric cyst. protein of 3 (normal range 0 – 10 mg/L). An ultrasound
examination was not performed. She was discussed with the
gynecology team who agreed with our management plan to
perform a diagnostic laparoscopy and was available to attend
Case report theater if required.
Diagnostic laparoscopy was performed via a 10 mm infra-
A 25-year-old woman presented to the acute surgical team umbilical camera port and a 5 mm left iliac fossa instrument
with a 24-hour history of sudden onset generalized abdominal port. A small collection of pus was noted in the pelvis although
pain, worsening in severity. She had an associated fever, malaise the uterus, ovaries and appendix were macroscopically normal.
and anorexia. She did not complain of any urinary symptoms, The pus subsequently showed pus cells on microscopy but no
dyspareunia or vaginal discharge. At the time of presentation, organisms were cultured. On inspection of the small bowel,
she was approximately midway through a regular menstrual primarily in search of a Meckel’s diverticulum, a 160 mm
length of cystic and nodular change involving the mid-ileum
a
Department of Colorectal Surgery, Queen Elizabeth Hospital, and neighboring mesentery was found. The rest of the small
Edgbaston, Birmingham B15 2TH, UK (Ward ST); bowel was normal. One cystic lesion on the posterior aspect
b
Department of Surgery, Worcestershire Royal Hospital, of the mesentery had ruptured with evidence of surround-
Charles Hastings Way, Worcester WR5 1DD, UK (Singh B,
ing induration [Fig. 1]. The left iliac fossa stab incision was
Jones TJ, Robertson CS)
lengthened to 40mm, creating a mini-laparotomy incision to
Conflicts of Interest: None enable resection of the effected length of small bowel and a
Correspondence to: Mr ST Ward, C/o Mr Tariq Ismail, hand-sewn end-to-end bowel anastomosis was performed. The
Department of Colorectal Surgery, Queen Elizabeth Hospital, resected bowel was opened along its antimesenteric border
Edgbaston, Birmingham B15 2TH, UK; Tel.: +4407904216421; and cystic disease affecting both the mesentery and bowel
e-mail: [email protected]
wall was confirmed [Fig. 2]. Her post-operative course was
Received 28 February 2011; accepted 12 April 2011 uneventful and she was discharged home 5 days after surgery.

© 2011 Hellenic Society of Gastroenterology www.annalsgastro.gr

138 S.T. Ward et al

Figure 1 Intra-operative photograph of segment of small bowel af-

fected by mesenteric and intestinal cystic disease showing the ruptured
infected mesenteric cyst abutting the bowel wall

Figure 3 Hematoxylin and eosin stained sections of microscopic find-

ings, magnification x100. Mucosa and submucosa (a) show dilated
lymphatics. Serosal fat (b) shows dilated lymphatics with evidence
of acute inflammation
Figure 2 Resected segment of small bowel opened along its antimes-
enteric border. Cystic disease affecting both the mesentery and all
layers of the small bowel wall can be seen prompting investigation or thirdly, approximately one third
of patients develop complications and present acutely as in
our case.
Histology identified these changes as localized intestinal Complications include bowel obstruction and volvulus
and mesenteric lymphatic cyst disease. Dilated lymphatic [2], hemorrhage [3], infection and rupture. Rupture of a
channels were noted to extend throughout the full thickness spontaneously infected mesenteric cyst is extremely rare.
of bowel wall and into the mesentery [Fig. 3]. To our knowledge there are only three other reports in the
literature. One case was a middle-aged male with a known
asymptomatic 12 cm intra-abdominal cystic lesion treated
conservatively for nine years before presenting acutely once
Discussion the cyst had become infected and ruptured [4]. Another case
was of an 18-year-old female presenting acutely and found
Intestinal and mesenteric cystic disease is rare and has to have a lower abdominal cystic lesion on ultrasound prior
been estimated to account for one in 100,000 acute surgi- to laparotomy [5]. In both these cases Staphylococcus aureus
cal admissions [1]. Diagnosis is established via one of three was cultured from the peritoneal fluid. The third case was
routes: Firstly, patients may be asymptomatic and the disease a pediatric patient again treated by laparotomy following
is discovered coincidentally on imaging or intra-operatively. acute presentation, although this time Escherichia coli was
Secondly, patients may present with non-specific symptoms cultured [6]. An ultrasound was also performed in this

Annals of Gastroenterology 24
 Ruptured infected mesenteric cyst 139

case showing a multilocular cystic structure in the lower the small bowel and its mesentery is conducted for both a
abdomen suspicious of an ovarian cyst. Ultrasonography Meckel’s diverticulum and mesenteric cystic disease.
is frequently performed in women presenting acutely with
lower abdominal pain to diagnose ovarian cysts and in this,
albeit rare case, can lead to misdiagnosis. It has been sug-
gested that CT and MRI are better modalities to decipher References
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Annals of Gastroenterology 24