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HUGE OMENTAL CYST MAY MIMIC ASCITES: A Rare Presentation

SANGRAM SINGH*, DHARMENDRA SINGH*,SARITA S BHAGWAT**

*Senior Resident; **Associate Professor, Department of Paediatric Surgery, BJ Wadia Hospital for Children, Parel, Mumbai 12.

Omental cyst is rare intra-abdominal pathology. Clinical presentation depends on the size of the cyst. Small cyst may be asymptomatic or it may present with acute abdomen. A big omental cyst may mimic ascites.

We have treated a case of omental cyst presented as ascites. Patient was investigated for all the possible causes of ascites but none of them came positive. Ultimately abdominal exploration was done; on exploration there was a huge omental cyst. Cyst was excised successfully.


INTRODUCTION

Omental cyst is rare cyst and mostly derived from lymphatic tissue.1 They are present on the lesser or greater omentum and lined by epithelium. Omental cyst occurs in all age groups but most often presents in children and young adults.

Children with omental cyst present with deceptive signs causing diagnostic problems. It can present as abdominal lump, acute abdomen or ascites. Huge omental cyst posing diagnostic dilemma is reported.

CASE REPORT

A 6 years old male child presented to us with gradual abdominal distension for last 1 1/2 years. There was no history of vomiting, fever, jaundice, swelling over face, lower limb or arrest of motion or flatus. On examination patient’s general condition was good, child was afebrile, heart rate was 88 per minute. Pallor present, no icterus, no oedema, no lymphadenopathy. His blood pressure was 108/66 mm of Hg. On per abdomen examination, there was generalized distension. No tenderness, no dilated veins over skin. Liver and spleen were not palpable. On percussion there was dull note all over the abdomen. Fluid thrill was present. On investigation haemoglobin was 12.7 gm%,, platelets were adequate, ESR was 35 at 1 hr, albumin = 3.6, globulin = 2.9) Uric acid = 4.4 mg% and LDH was 481 mg%. USG abdomen was suggestive of ascites; no evidence of hepato-splenomegaly and lymphadenopathy. CT abdomen findings were extensive fluid in the peritoneal cavity suggestive of ascites. No lymphadenopathy seen (Fig. 1).

Fig.1
Fig.1 CT absomen showing fluid in the peritoneal cavity, lymphnodes not seen

In view of ascites abdominal cavity was tapped and sent for examinations. Ascitic fluid was slightly haemorrhagic with 3040 cells mainly highly atypical lymphocytes. In ascitic fluid TB antigen was negative, absence of malignant cells, amylase was 10 iu/dl, no bile pigments or salts present.

Patient was treated on medical line of management but did not responded. Ultimately diagnostic laparotomy was planned. On opening the abdomen surprisingly it was a huge omental cyst which was arising from the greater omentum with twist and turn at the pedicle. Cyst was excised completely and post op recovery was uneventful. Cyst was 12" x 10" in size and 5.3 kg in weight (Fig. 2 ).

Fig.2
Fig.2 Shows cyst of 12'x 10"size.


Histopathology of specimen was omental cyst with endothelial lining and haemorrhagic fluid inside.

DISCUSSION

True incidence of omental cyst is much more higher as compared to cases reported in literature because usually cyst of clinical importance has been reported.2 The classical presentation of omental cyst is low grade partial intestinal obstruction with palpable freely mobile abdominal mass,2 however the lump is palpable in 25-50% of cases only.3 The cysts are incidental findings in approximately 40% of the cases.1,4,5 Omental cyst is lined by a distinct membrane similar to cavernous lymphangioma. It shows abnormal localized collection of fluid that may be bloody, serous or chylous. Small omental cyst may be asymptomatic but large cyst can present as acute abdominal emergencies such as acute intestinal obstruction, or volvulus, or sudden haemorrhage into the cyst, or infection. The cyst often has a flaccid consistency and tend to “flowout” and “fillout” the dependent parts of the abdominal cavity and interpose between the structures. Usually the diagnosis of omental cyst is made by exclusion of other diseases.6 In the present case abdomen was increasing gradually and by the time patient came to us cyst increased enormously and was occupying the entire abdomen, thus simulating ascites. USG and CT scan of the abdomen failed to delineate the cyst due to large size. So in any case of huge abdominal distention if other causes of ascites are ruled out large omental or mesenteric cyst should be considered. The known complication of omental cyst are torsion, infection, rupture, haemorrhage and acute compression of neighbouring structures.1,7 If the cyst encountered incidentally, it should be removed. The operative mortality for excision of omental cyst is negligible. Prognosis is good since omental cyst shows no documented tendency for malignant degeneration or recurrence.

REFERENCES:

1.Walkar AR, Putham TC. Omental, mesenteric and retroperitoneal cyst. A clinical study of 33 new cases. Ann Surg 1973; 178 : 13-19.

2. Periello VA, Flemma RJ. Lymphangiomatous omental cyst in Infancy masquerading as ascites. J Peds Surgery 1969; 4 : 227.

3. Burnett WE, Rosemond GP, Bucher RM. Mesenteric cyst. Arch Surg 1950; 60 : 699-705.

4. Sardi A, et al. Mesenteric cyst. Ann Surg 1987; 53-58.

5. Vanek VW, Philips AK. Retroperitoneal mesenteric and omental cyst. Arch Surg 1984; 119 : 838.

6. Berahrs OH, Jadd ES, Docherty MD. Chylous cyst of the abdomen. Surg Clinic of North America 1950; 30 : 1081-96.

7. Oliver GA. The omental cyst : a rare case of the acute abdomen crisis. Surgery 1964; 56 : 588.


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