Gastrointest Radiol 16:311-314 (1991)

Gastrointestinal
Radiology
9 Springer-Verlag New York Inc. 1991
Mesenteric and Omental Cysts: An Ultrasonographic and Clinical
Study of 15 Patients
Yi - Hong Chou, 1 Chui - Mei Ti u ] Wi ng-Yi u Lui , 2 and Ts uen Chang ~
Departments of 1 Radiology and ~ Surgery, Veterans General Hospital-Taipei, and National Yang-Ming Medical College, Taipei,
Taiwan, Republic of China
Abstract. The cl i ni cal and ul t r asonogr aphi c (US)
f eat ur es of 15 cases of mes ent er i c or oment al cys t
ar e her ei n descr i bed. Thi s seri es i ncl uded s even
mal e and ei ght f emal e pat i ent s, whos e age r anged
f r om 2- 89 year s. Cor r e ct clinical di agnosi s was
made in t wo chi l dr en onl y, but pr eoper at i ve US ex-
ami nat i on accur at el y demons t r at ed t he l esi on in 11
of 13 pat i ent s (85%). Thes e cyst i c l esi ons usual l y
had a t hi n wall, i nt er nal sept at i ons, and fluid cont ent
wi t h sedi ment at i on. Ent er i c dupl i cat i on cyst s had a
r el at i vel y t hi ck wal l mer gi ng wi t h t he muscl e l ayer
of bowel l oop, and mul t i l ocul at i on was not ed mai nl y
wi t h cyst i c l ymphangi omas or ps eudocys t s . The di-
agnost i c and surgi cal ma na ge me nt of t hese l esi ons
ar e bri efl y r evi ewed and t hei r US appear ance is illus-
t r at ed.
Key words: Abdome n, u l t r a s o u n d - Mes ent er i c
cyst , s y mpt o ms - - Ome n t a l cys t , d i a gn o s i s - - E n -
t er i c dupl i cat i on.
Mes ent er i c and oment al cyst s ar e uncommon le-
sions wi t h a pr evi ous l y r epor t ed i nci dence of 1 per
100-250 t hous and hospi t al admi ssi ons [1]. Har di n
and Ha r dy [2] di agnosed six cases among 161,944
pat i ent s and suggest ed t hat t hes e l esi ons mi ght have
occur r e d wi t h a hi gher f r e que ncy t han expect ed.
Mes ent er i c and oment al cyst s do not have speci fi c
signs or s ympt oms t o al l ow t hei r clinical di agnosi s
[3]. Si nce t wo initial r epor t s of t hes e sonogr aphi c
appear ance in 1975 [4, 5], however , such l esi ons
have be e n de t e ct e d wi t h an i ncr easi ng f r e que ncy [ 6-
Address of f pri nt request s to: Yi-Hong Chou, M.D., Department
of Radiology, Veterans General Hospital-Taipei, Taipei, Taiwan
11217, ROC
11]. Thi s art i cl e pr es ent s our exper i ence wi t h 15 ad-
di t i onal cases eval uat ed at our i nst i t ut i on duri ng t he
past 12 year s.
Materials and Methods
Fifteen cases of mesenteric/omental cysts were collected in Vet-
erans General Hospital--Taipei from January 1978 to December
1989. All patients were operated on due to abdominal pain and/or
imaging-proved abdominal mass. There were seven male and
eight female patients, ranging in age from 2-89 years (average
age, 42 years). Ultrasonography (US) was performed in 13 of 15
patients using 3.5-5.0 MHz transducers. The echopatterns, inter-
nal natures, wall thickness, and localization demonstrated by US
were recorded. The clinical manifestations, 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 computerized data.
Results
The r e wer e a t ot al of 15 pat i ent s wi t h pat hol ogi cal l y
pr ove n me s e nt e r i c/ ome nt a l cyst s in 475,502 admi s-
si ons dur i ng t he past 12 year s. The i nci dence was
1/32,000. The hi st ol ogi c cl assi fi cat i on i ncl uded cys-
tic l ymphangi oma (2 cases) , ent er i c dupl i cat i on cyst
(2), mesot hel i al cys t (5), and nonpancr eat i c pseudo-
cys t (6) ( Tabl e 1). The mos t common clinical mani -
f est at i ons wer e abdomi nal pai n (9 of 15 pat i ent s) and
pal pabl e mass (7 cases) , f ol l owed by abdomi nal dis-
t ent i on, vomi t i ng, and var i ous nonspeci f i c findings.
A cor r ect cl i ni cal i mpr essi on was not ed in onl y t wo
pedi at r i c pat i ent s. Abdomi nal films a nd/ or i nt r ave-
nous ur ogr aphy wer e r evi ewed in 14 pat i ent s, and
onl y six cases (40%) s howed i nt r aabdomi nal soft tis-
sue mass. Bar i um e ne ma in t hr ee chi l dr en r eveal ed
mi ni mal mass ef f ect in onl y one pat i ent wi t h a l arge
mesot hel i al cyst . El e ve n of t he 13 pat i ent s r ecei vi ng
312 Y-H. Chou et al.: Mesenteric and Omental Cysts
Fig. 1. An 89-year-old man with a large mesothelial cyst (arrows):
The lesion is echo-free, occupying the whole mid-abdomen, and
displacing the small intestine upward and downward. LK, left
kidney.
Fig. 2. A 4-year-old boy with a cystic lymphangioma (arrows):
Multiple septa (arrowheads) are evident in this lobulated cystic
mass.
Fig. 3. A 3-year-old girl with an infected pseudocyst (arrows):
Small echogenic structure in the dependent portion (arrowhead)
represents debris. LK, left kidney.
Fig. 4. A 9-year-old boy with a hemorrhagic pseudocyst (arrows):
Formed, septated internal echoes are present due to clotted
blood. LK, left kidney.
Fig. 5. A 6-year-old girl with an enteric duplication cyst (arrows):
A large thick-walled cystic lesion extends to the ileal wall (arrow-
heads). The fine septation may be due to infection. UB, urinary
bladder.
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 without septa-
tion was most 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 l ymphangi 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
duplication cysts ( >3- 5 mm) (Fig. 5) and in one case
of pseudocyst (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-
t ery of the small bowel.
Comput ed t omography (CT) was performed in
five patients (two children and three adults). CT re-
vealed similar characteristics as shown in US exami-
nation except t hat some sedimentation and septa-
tion were not demonst rat ed, especially those in a
pseudocyst. CT demonst rat ed the anatomic relation-
ship bet ween 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
Y-H. Chou et al.: Mesenteric and Omental Cysts
Tabl e 1. Classification and diagnosis of mesenteric/omental cysts
313
Classification Case no. Sex/age Size
(cm)
Correct
preoperat i ve
US diagnosis
Cystic lymphangioma 2
Enteric
duplication cyst 2
Mesothelial cyst 5
Pseudocyst 6
(nonpancreatic)
Total 15
M/2 yr, M/6 yr 15, 24 2/2
F/ 6 yr, F/61 yr 8, 10 2/2
4-89 yr 3-25 4/4
(3 M, 2F)
3-64 yr 5-20 3/5
(2M, 4F)
2 yr-89 yr 3-25 11/13
Tabl e 2. US appearances of mesenteric/omental cysts
US findings Histologic classification
and number
Thick wall (3-5 mm) Enteric duplication cyst
Pseudocyst
Septa
Numerous Pseudocyst 2
3-5 Cystic lymphangioma 2
1-3 Mesothelial cyst 2
Internal echoes
Weak, diffuse Mesothelial cyst 2
Enteric duplication cyst 1
Formed sediments Mesothelial cyst 2
Cystic lymphangioma 1
Pseudocysts 1
Thin wall, no septa Mesothelial cyst 3
Pseudocyst 3
as segmental resection of terminal ileum and cecum
in the other (duplication cyst of the terminal ileum)
were needed. All patients were followed for 3
months to 7 years and all had uneventful recoveries.
Di scussi on
The incidence of omental and mesenteric cysts at
our hospital was 1 per 32,000 admissions, whereas
Hardi n and Har dy found 1 per 27,000 admissions [2].
Ros et al. [11] recent l y classified these lesions into
five groups, consisting of lymphangioma, enteric du-
plication, mesenteric or mesothelial cyst, and non-
pancreatic pseudocyst s. 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 sympt oms are mani-
fested when the lesions attain a large size: t hey
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, i nfect i on, 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 patients 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 enucleation 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 l ymphangi oma was treated by excision of the
cyst and segmental resection of the small bowel be-
cause of their tight adhesion and the compromised
vasculature. In anot her patient with duplication cyst
of the terminal ileum, partial cyst ect omy and seg-
mental resection of ileum and cecum were per-
formed. Accidental rupture of the cysts during surgi-
cal procedure was encount ered 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 ot her single imaging modality can pro-
vide more information 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
noncont rast -enhanced septa most likely result from
an old hemorrhage, which is more commonl y en-
countered in a traumatic pseudocyst . A thick-walled
lesion merged with the muscle layer of the bowel is
most likely an enteric duplication cyst because it has
a muscle layer, as well as a mucosal lining predomi-
314 Y-H. Chou et al.: Mesent eri c and Oment al Cyst s
nantly similar to that of the adjacent alimentary tract
[14]. The fine and faint internal echoes in an enteric
duplication cyst, which may be accompanied by in-
terlacing septa, are either due to mucus collection or
infection of the cyst.
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Recei ved: November 2, 1990; accept ed: December 10, 1990