MD Ped

PhD Ped and children special need

Personal history
Raania M A 4-year-old girl from weish Dk first kid of
non cosanguious marriage with low social state


Complaint
Patient referred for evaluation of abdominal
enlargement low grade nocturnal fever
History of the present illness
She was born at full term, and her growth and
development were normal. Her past medical history
was unremarkable
until she presented with abdominal distension and
mild constipation at the age of 36 months.
No other symptoms were present at that time.
There was no family history of gastrointestinal
disorders, liver or pancreas disease, or cancer. There
was no history of allergy to medication and her
immunizations were up to date.
On admission she appeared healthy.
Her vital signs were normal and fever peak 38c.
Weight and height were in the 50th percentile.
She had no adenopathy,, or jaundice.
Chest : BEAE
Heart S1 S2 O
.The abdomen was distended, soft and nontender, with
no masses palpable. A wave was felt but there was no
shifting dullness.
The spleen and liver were not enlarged.
Neurologic exam was normal.
The remainder of the physical exam was normal.
Investigation ordere

CBCs
TLC:9.6
RBCs: 3.64
HB: 10
PLAT: 296
Total serum protein, 7.3 g/dL;
serum albumin, 4.2 g/dL;
serum cholesterol, 153
serum lactate dehydrogenase;320
uric acid; 3.6
liver enzyme (ALT 25 mg, AST 30, ,alkaline phosphatase 370 KAU
gamma glutamyltransferase;118 prothrombin time 12 and international
normalized ratio1.1
Thyroid function tests;
urine analysis. Normal finding
A tuberculin skin test was negative
Radiological study ordere
CXR : normal finding
The ultrasound abdominal Ex Revealed:
A large fluid collection with septation. The
collection extended from the upper abdomen to the
pelvis.
The bowel loops were displaced posteriorly.
The liver, spleen, and pancreas were normal.
A Doppler study showed normal portal and splenic
venous and arterial flow .The inferior vena cava and
the aorta appeared normal.

Radiological studyordere Axial tomograph
Abdominal CT scan report
A large amount of intraperitoneal fluid and no definite
septation. The fluid surrounded the organs including
the spleen, The bowel was compressed in the midline
around the mesentery. The liver was normal in size
and contour and enhanced homogeneously without
evidence of focal lesion. There was no intrahepatic
biliary dilatation seen. The spleen was normal in size
and enhanced homogeneously. The pancreas, adrenal
glands, and kidneys were normal and there were no
masses present in the abdomen or the pelvis.
NEXT STEP INVASIVE MANOVER
A paracentesis was performed
Aspiration of 650 mL of yellow fluid was removed.
A paracentesis fluid Analysis bacteriological and
biochemical

revealed the following: no bacteria on Gram stain;
negative bacterial culture;

WBC count,( 620 cells/mm
3
; with 84% lymphocytes,
7% histiocytes, and 8% eosinophils;)
Total protein, 3.7 g/dL;
Albumin, 1.9 g/dL;
Cholesterol, 63 mmol/L; Triglycerides, 25 mmol/L;
Amylase < 30 mmol/L; and lactate, 0.9 mmol/L.
The serum glucose was 95 mg/dL;
WHAT ELSE how manage

Surical Exploration:
Laparotomy was performed
A large multicystic mass, 22 18 2.8 cm, weighing
1840 g was found beneath the peritoneum. It
originated from the omentum and had a narrow
pedicle. The walls were thin and translucent septa
were present.



Histopathological study
Histologic analysis revealed cystic spaces lined by flat
endothelial cells. Aggregates of lymphoid tissue were
seen in the wall of the cysts, which were composed of
vessels and adipose tissue.


Final Etiologic Diagnosis

Omental cyst.
Surgically removed and the child is doing well.









Cystic lesion of the omentum and mesentery are rare.
The incidence of both cyst types has been variously
reported to vary from 1/27,000-100,000 hospital
admission. Omental cysts occur three to ten times less
frequently than mesenteric cyst. Preoperative
diagnosis is infrequently made because of lack of
characteristic symptoms and signs.
Cystic lesion of the omentum, mesentery and
retroperitoneum have been grouped together in the
same category by several authors because they are
similar embryologically and pathologically
According to Conzo et al [1], mesenteric and omental
cysts are congenital abdominal lesions. However, most
reported cases as in this presentation occurred in
adult, while only about one third of cases are reported
in children younger than 15 years [2]. Probably, the
benign nature of these cysts, their generally
asymptomatic nature unless when complicated and
the non-hindrance on patient day to day activities
makes affected patient not to present for medical
attention until gross abdominal swelling had set in
Omental cysts are usually differentiated from ascites
by the fact that it is not associated with flanks bulging
during recumbency since the cyst will follow as the
patient moves.

Ultrasonography in this patient revealed
multiseptated cyst having some solid components and
features suggestive of internal haemorrhage.
The goal of surgical therapy is complete excision of the
mass, which sometimes may require inclusion of the
adjacent structures

The goal of surgical therapy is complete excision of the
mass, which sometimes may require inclusion of the
adjacent structures
1-Conzo G, Vacca R, Grazia Esposito M, Brancaccio U,
Celsi S, Livrea A. Laparoscopic treatment of an
omental cyst: a case report and review of the literature.
Surg Laparosc Endosc Percutan Tech. 2005;15:3335.
2-Rahman GA, Johnson A-WBR. Giant Omental Cyst
simulating ascites in a Nigerian Child: case report and
critique of clinical parameters and investigative
modalities. Ann Trop Paediatr. 2001;21:8185. doi:
10.1080/02724930020028975