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An 18-year-old male college student came to the emergency department with a history of diffuse abdominal pain, diarrhea, and fevers for 2 days. He had not noticed a change in eating habits, abdominal girth, or weight. On examination, vital signs were within normal limits; a firm, nontender mass of 20 cm in diameter was palpated in the left upper abdomen. Aside from a white blood cell count of 13 000/μL, all other hematologic or chemistry laboratory parameters were normal.
Abdominal radiographs showed a normal gas pattern with shifting of the small intestine to the right, combined with a lucency of the left upper quadrant. Abdominal computed tomography demonstrated a multicystic septated retroperitoneal mass primarily involving the small bowel mesentery, with compression of the distal duodenum (Figure 1A, black arrows). There was displacement of the superior mesenteric artery and vein but no evidence of mesenteric vascular encasement (Figure 1A, white arrows). T2-weighted magnetic resonance imaging did reveal a high fluid content within the multicystic mass (Figure 1B).
A, Axial computed tomography image of the abdomen. A large, multicystic mass compresses the duodenum (black arrows) and extends to the superior mesenteric artery and vein (white arrows). B, Appearance of the mass on a T2-weighted magnetic resonance image.
Intraoperatively, there was no evidence for metastatic disease; the mesenteric mass did not involve intraperitoneal structures and was readily mobilized. The mass was resected in continuity with a short segment of proximal jejunum, which was found to be attached; superior mesenteric arterial and venous branches were preserved (Figure 2, arrows). The patient had an uneventful recovery and had no recurrence of his symptoms within a year of the operation.
Intraoperative picture after dissection of the mass off the superior mesenteric vasculature (arrows).
A. Complex intestinal duplication cyst
B. Multicystic lymphangioma
C. Desmoplastic small round cell tumor
D. Retroperitoneal cysticercosis
Vogel TR, Hammond JS, Schwarz RE. Image of the Month—Quiz Case. Arch Surg. 2005;140(4):411. doi:10.1001/archsurg.140.4.411