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Special Feature
March 2010

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: Department of Surgery, Oregon Health [[amp]] Sciences University, Portland (Dr Perkins); Departments of Surgical Gastroenterology (Dr Reddy) and Pediatric Surgery (Dr Lal), Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.



Arch Surg. 2010;145(3):307. doi:10.1001/archsurg.2010.13-a

A 7-year old male child had progressively increasing generalized abdominal distention of 7 months' duration. In the last 2 months, the child's appetite had diminished, and he had both early satiety and postprandial fullness. There was no alteration in his bowel habits. His medical history, family history, and social history were unremarkable. The patient was not taking any medications, and there were no allergies. There was no history of exposure to tuberculosis.

On physical examination, the child's nutritional status was visibly impaired, with evidence of growth retardation for his stated age. On abdominal examination, the patient was visibly and symmetrically distended. Bowel sounds were not audible. His abdominal girth was measured to be 70 cm. The abdomen was soft and nontender to palpation. There was no evidence of organomegaly, but liver and spleen contours were difficult to appreciate. A fluid thrill was present, but without shifting dullness. A distinct band of resonance was present in the epigastrium and left upper quadrant. Results of cardiovascular, pulmonary, and neurovascular examination were unremarkable.

Ultrasound of the abdomen showed a large anechoic lesion occupying the entire abdomen, with multiple echogenic septae in the abdomen and pelvis. Contrast-enhanced computed tomography of the abdomen showed a large hypodense cystic lesion occupying almost the entire abdominal cavity that measured 21 × 14 × 22 cm, displacing the large and small bowel laterally and inferiorly, with a few enhancing septae seen within the cystic lesion (Figure 1).

Figure 1. Computed tomographic image of the abdomen.

Figure 1. Computed tomographic image of the abdomen.

The patient underwent laparotomy, which demonstrated a large, multiloculated cystic lesion measuring 25 × 22 × 7 cm, arising from the root of the mesentery and extending from the duodenojejunal flexure superiorly to the proximal sigmoid colon inferiorly (Figure 2). There was no evidence of abdominal lymphadenopathy. The mass was removed in its entirety. Pathologic gross examination revealed a multicystic lesion filled with clear fluid. Microscopic examination showed multiple cystic spaces with flattened endothelium. The stroma was composed of loose fibroconnective tissue with occasional muscle fibers and adipocytes, and displayed prominent lymphoid cell aggregates.

Figure 2. Intraoperative photograph of the abdominal mass at laparotomy.

Figure 2. Intraoperative photograph of the abdominal mass at laparotomy.

What Is the Diagnosis?

A. Loculated ascites

B. Lymphangioma

C. Retroperitoneal neoplasm

D. Hydatid cyst