A ruptured infected mesenteric cyst diagnosed on laparoscopy for suspected appendicitis
A 25-year-old woman presented to the acute surgical team with a 24-hour history of sudden onset generalized abdominal pain, worsening in severity. She had an associated fever, malaise and anorexia. She did not complain of any urinary symptoms, dyspareunia or vaginal discharge. At the time of presentation, she was approximately midway through a regular menstrual cycle. She was otherwise fit and well with no previous medical history and on no regular medications. She did admit to a diarrheal illness one month previously during which an out-patient stool culture had grown Campylobacter jejuni.\nOn examination, she was noted to be tachycardic with a heart rate of 110 beats per minute and fever at 38.0°C. She was tender throughout the lower abdomen, mostly in the suprapubic area with guarding. Urinalysis was negative for blood, nitrites and leukocytes and a urinary pregnancy test was negative. Her blood investigations revealed a raised white cell count of 19.1 (normal range 4 – 11 109/L) and a C-reactive protein of 3 (normal range 0 – 10 mg/L). An ultrasound examination was not performed. She was discussed with the gynecology team who agreed with our management plan to perform a diagnostic laparoscopy and was available to attend theater if required.\nDiagnostic laparoscopy was performed via a 10 mm infraumbilical camera port and a 5 mm left iliac fossa instrument port. A small collection of pus was noted in the pelvis although the uterus, ovaries and appendix were macroscopically normal. The pus subsequently showed pus cells on microscopy but no organisms were cultured. On inspection of the small bowel, primarily in search of a Meckel’s diverticulum, a 160 mm length of cystic and nodular change involving the mid-ileum and neighboring mesentery was found. The rest of the small bowel was normal. One cystic lesion on the posterior aspect of the mesentery had ruptured with evidence of surrounding induration []. The left iliac fossa stab incision was lengthened to 40mm, creating a mini-laparotomy incision to enable resection of the effected length of small bowel and a hand-sewn end-to-end bowel anastomosis was performed. The resected bowel was opened along its antimesenteric border and cystic disease affecting both the mesentery and bowel wall was confirmed []. Her post-operative course was uneventful and she was discharged home 5 days after surgery.\nHistology identified these changes as localized intestinal and mesenteric lymphatic cyst disease. Dilated lymphatic channels were noted to extend throughout the full thickness of bowel wall and into the mesentery [].