1 / 100

By Donnie Rose Torres, MD October 3, 2013 ICU Conference Room

GRAND ROUNDS. Mesenteric and Omental Cyst In An Infant. By Donnie Rose Torres, MD October 3, 2013 ICU Conference Room. To present an approach to a case of abdominal distension in an infant

lena
Download Presentation

By Donnie Rose Torres, MD October 3, 2013 ICU Conference Room

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. GRAND ROUNDS Mesenteric and Omental Cyst In An Infant By Donnie Rose Torres, MDOctober 3, 2013ICU Conference Room

  2. To present an approach to a case of abdominal distension in an infant • To discuss the approach to diagnosis, incidence, management, complications and prognosis of patients with mesenteric and omental cyst • To present hemangiolymphangioma as a histological finding for mesenteric and omental cyst Objectives

  3. RA DG, 1-month old female from Calbayog, Samar admitted from AFP Medical Center coordinated transfer to our institution last June 29, 2013 Chief Complaint: ABDOMINAL DISTENSION Patient’s Data

  4. History of Present Illness

  5. History of Present Illness

  6. History of Present Illness

  7. History of Present Illness

  8. History of Present Illness

  9. History of Present Illness

  10. History of Present Illness

  11. History of Present Illness

  12. History of Present Illness

  13. General:(-) weight loss Skin: (-) excessive dryness ENT: (-)epistaxis, (-)excessive salivation , (-) eye and ear discharge Neck: (-)limitation of movement Respiratory: (-)cough, (-) colds, (-) difficulty of breathing Review Of Systems

  14. Gastrointestinal: (-) vomiting, regular bowel movement, (-) constipation, (-) hematemesis, (-) melena, (-) hematochezia, (-) acholic stools Endocrine: (-)polyuria, (-) polydipsia Genitourinary: (-)discharge, (-) genital rashes, (-) hematuria Musculoskeletal: (-)limitation of movement Nervous system: (-) irritability, (-) changes in activity Review Of Systems

  15. (+) history of DM – paternal side (+) history of Hypertension – maternal side (-) history of Asthma, Malignancy, TB, Renal and Hepatic diseases on both sides 26 housewife 21 soldier Family History

  16. (+) BCG • (+) Hepatitis B 1st dose - given upon birth Immunization History

  17. Exclusively breastfed Nutritional History

  18. No history of blood transfusion • No allergies to drugs Past Medical History

  19. lives with parents and 3 other relatives • 2-storey, 3-bedroom house • owned by their family • (-) exposure to smoking • (-) exposure to chronic cough • use tap water for consumption • garbage collected thrice a week Personal and Social History

  20. General Survey: awake, not irritable, active Vital signs: BP: 80/50 Wt: 5.6 kgs (z score 2) BSA: 0.28 CR: 130 bpm Lt: 53 cm (z score 0) RR 34 cpm HC: 38 cm (z score 0) T: 36.7 oCCC: 35 cm AC: 44cm umbilical level, 46cm widest diameter Skin: jaundice from face to chest, warm, moist skin HEENT: open and flat anterior and posterior fontanelles, no molding, (+) erythematous maculopapular rashes on the face,anicteric sclerae, nonsunken eyeballs, pink palpebral conjunctiva, no nasoaural deformities and discharges, moist lips, no cleft lip, no cleft palate, no neck masses, no cervical lymphadenopathies Physical Examination

  21. Chest and lungs: no gross chest deformities, symmetric chest expansion, good air entry, clear breath sounds, no retractions Cardiovascular: adynamic precordium, no heaves nor thrills, regular rate and rhythm, distinct heart sounds, apex beat at 4th intercostals space mid-axillary line, no murmurs Genitalia:grossly female-looking genitalia Anus:patent anal opening Spine:straight spinal column, no spinal masses, no sacral dimpling, no tufts of hair Extremities:no polydactyly, no other deformities, no edema, full and equalpulses, good capillary refill time Physical Examination

  22. Abdomen: • distended, AC – 44 cm umbilical level, 46 cm widest diameter • (+) prominent abdominal veins • normoactivebowel sounds • Tympanitic • soft • (-) hepato-splenomegaly, • (+) 5 x 6 cm, solid, ill-defined mass palpated midline Physical Examination

  23. awake, active CN I: not assessed CN II:(+) dazzle CN II , III:pupils 2-3 mm equally reactive to light CN III, IV, VI:full and equal EOM CN V: not assessed CN VII:no facial asymmetry CN VIII:not assessed CN IX, X: good gag reflex CN XI: not assessed CN XII: tongue at the midline, no fasciculation Motor:Normal muscle bulk; Normal muscle tone; No fasciculation Sensory: withdraws to pain stimuli (+) Babinski, bilateral, No clonus Signs of Meningeal Irritation: (-)nuchal rigidity, Brudzinski sign: negative, Kernig sign: negative   Reflexes:(+) rooting, palmar, Moro Neurologic Examination

  24. Salient Features

  25. Salient Features

  26. Ascites vsPelvo-abdominal Mass, Pobably: 1. Ovarian cyst 2. Germ cell tumor 3. Mesenteric and Omental cyst No wasting, no stunting Working Diagnosis

  27. Abdominal distension hepatic ASCITES renal cardiac Approach to the Diagnosis Pregnancy/obesity tumors

  28. miscellaneous trauma OLDER CHILDREN ASCITES neoplasia infection Hepatocellular disease Gynecologic or GIT abN Approach to the Diagnosis

  29. Spontaneous perforation of the bile duct biliary Perforation of choledocal cyst NEONATAL ASCITES urinary Complex urinary anomalies Perforation of bladder or ureteral tract chylous Approach to the Diagnosis Idiopathic Congenital lymphatic Abn Hernia Intususception Neoplasm External compression of lymphatics

  30. Pertinent - • Feeding intolerance • Rare • Direct hyperbilirubinemia • UTZ findings • Pertinent + • Age group (< 3 months) • Mild jaundice • Abdominal distension biliary • Pertinent + • Abdominal distension NEONATAL ASCITES urinary • Pertinent - • Male predominance • Prenatal UTZ • oligohyramnios • Metabolic acidosis • Elevated BUN/Crea • Electrolyte ABN chylous Miscellaneous Cardiac Infection Approach to the Diagnosis • Pertinent + • Congenital • Abdominal distension • UTZ and CT Scan findings • Pertinent - • Feeding intolerance • Male predominance

  31. Idiopathic CHYLOUS ASCITES Mesenteric/Omental Cyst Congenital lymphatic Abn Hernia Ovarian Mass External compression of lymphatics Intususception Approach to the Diagnosis Tumors/Neoplasm Germ cell tumors hepatoblastoma

  32. Assessment of Abdominal Mass Ch 78, by RH Sills Practical Algorithms in Hematology and Oncology

  33. Assessment of Abdominal Mass Ch 78, by RH Sills Practical Algorithms in Hematology and Oncology

  34. Assessment of a Pelvic Mass Ch 80, by RH Sills Practical Algorithms in Hematology and Oncology

  35. Ascites vsPelvo-abdominal Mass, Pobably: 1. Ovarian cyst 2. Germ cell tumor 3. Mesenteric and Omental cyst No wasting, no stunting Working Diagnosis

  36. 1stHosp day • Jaundice • Distended abdomen • Prominent veins • Soft • No organomegaly • Ill defined mass • The rest of PE and Neuro exam NORMAL LABS Course In the Wards

  37. 1stHosp day • Heplock • DBF • Gyne, Hema and Surgery • HEMA: • A> Pelvo-abdominal Mass prob ovarian in origin, r/o GCT • Hydration • Aluminum Hydroxide • Monitoring of Tumor Markers • JAUNDICE LDH BHCG AFP • TUMOR MARKERS • GYNE/SURG: • A> Pelvo-abdominal Mass prob ONG • Ex-Lap Course In the Wards

  38. 2ndHosp day • WARDS • Gr 2/6 HS murmur 2nd ICS LPSB • IVF mtn rate 2 d echo: PFO Salbutamol neb IVF mtn rate • Hyperkalemia • Hypercalcemia • Rpt LABS • Normokalemia • Hypercalcemia • Normal U/A • Uncompensated Metabolic acidosis • A> T/C TumorLysis Syndrome, Hypercalcemia of Malignancy Hydration 2L/BSA Course In the Wards

  39. 2ndHosp day • Hyperkalemia • Hyperphosphatemia • Hyperuricemia • Hyperuricosuria • Hypocalcemia • Lactic acidosis • TUMOR LYSIS SYNDROME • Vs Pre-treatment spontaneous TLS • Treatment • Targeted to specific metabolic disorder • Hyperkalemia – pushes K back intracellularly • Hyperphosphatemia – hydration, AlOH • Acidosis – Hydration, NaHCO3 • Laboratory TLS • Cairo-Bishop definition • Clinical TLS Course In the Wards

  40. 2ndHosp day • HYPERCALCEMIA • OF MALIGNANCY • Treatment • Targeted to underlying cause • Hydration – decreased Ca through dilution, incraeses renal Ca clearance • Forced diuresis – increased Ca excretion, avoid volume overload, increase Ca reabsorption • Bisphophonates – inhibit osteoclast activity Course In the Wards

  41. 6th to 9th Hosp day • Pre-op Conference • Pre-op Labs Course In the Wards

  42. Ascites vsPelvo-abdominal Mass, Pobably: 1. Ovarian cyst 2. Germ cell tumor 3. Mesenteric and Omental cyst No wasting, no stunting Working Diagnosis

  43. 10thHosp day • Marsupialization of the mesenteric cyst • Exploratory Laparotomy • Intra-op findings: • Mesenteric cyst occupying almost all of the small intestine mesentery extending to the retroperitoneal space • Intra-op findings: • 5 x 7 cm omental cyst with chylous contents • Milky ascites Course In the Wards

  44. Mesenteric and OmentalCyst S/P Excision of Cyst and Marsupialization of Mesenteric Cyst (7/8/13), Chylous ascites No wasting, No stunting Working Diagnosis

  45. Mesenteric and Omental Cyst

More Related