Total Mechanical Bowel Obstruction Due to Small Bowel

Volvulus With Mesenteric Cyst

Resident of General Surgery, Department of Surgery, Medical Faculty of Sumatera Utara

Connsultan Sub Division of Digestive Surgery, Department of Surgery, Medical Faculty,
University of Sumatera Utara

Introduction

Mesenteric cyst is a rare tumor cases. It is accompanied by the occurrence of total mechanical
bowel obstruction due to mesenteric cyst with Small Bowel volvulus. Here, we report a case
of including etiology, clinical history and characteristics, the type of surgery used, and
treatment options.

Material and Method

A 16 year old boy came with complaints of abdominal pain through out the field. The case
reports taken at an emergency hospital Haji Adam Malik Medan in February 2016.

Result

Case Report

A 16 year old boy, came to the emergency hospital Haji Adam Malik Medan with complaints
of pain in the whole abdomen, This is true since one week before to the admissions and
increasing pain since 4 today. It felt continuosly especially worsent if it pressure. Previous
patien hospitalized outside for 4 days, with conservative treatment is done. Then the patient is
referred to hospital Haji Adam Malik Medan. Last defecation since 1 week ago. Nausea,
vomiting founded especially when eating, and out what to eat. Patient with histroy of
laparatomy appendectomy operation about 4 years ago. Physical examination with awareness
alert, blood pressure of 130/80 mmHg, Heart rate 87 pulse per minute, respiratory rate 20
times per minutes. Abdominal examination discovered distension, pain on the whole
abdomen, defans muscular, abdominal tenderness around the field, and auscultation
peristaltic inaudible. Laboratory tests leucocytosis (22,1) and hiponatremia (123). Overview
erect abdominal x-rays founded multiple air fluid level, and supine abdominal x-rays found
air does not get to the recti.

Management of initial therapy do resuscitation 2 line with 2 liters of crystalloid fluids,

administration of broad-spectrum antibiotics and analgetic. Nasogastric Tube decompression
is done with the installation, and the catheter as fluid controller output.. After that, the
patients were prepared to do emergency exploration laparotomy with mesenteric cyst
marsupialization.

Patients to do midline incision opened came out serous fluid 300cc, identification seen small
bowel dilatation was bluish and dilatation 10 cm from the ligament of Treitz until ileo-caecal
junction. Identification seemed mesenteric cyst 7 cm of the ligament treitz. Looks twisted in
the mesentery. Twisted freed about 3600 and then compressed with NaCl 0,9% for 30
minutes, rated small bowel looks viable, and normal peristaltic. Mesentery cyst
marsupialization is done.

Postoperative patients were mounting Central Venous Catheter (CVC), fasted and diet
administration of Total Parenteral Nutrision for 3 days. Follow-up of patients with stable
hemodynamic, abdominal distension, normal peristaltic.

Discussion

Mesenteric cyst is one of the rarest abdominal tumours, with approximately 820 cases
reported since 1507. The incidence varies from 1 per 100,000 to 250,000 admissions. The
lack of characteristic clinical features and radiological signs may present great diagnostic
difficulties. The cyst may present in one of three ways: (i) non-specific abdominal features;
(ii) an incidental finding; or (iii) an acute abdomen. Abdominal pain is the major presenting
symptom. Abdominal mass is found in more than 50% of cases and 40% of cases are
discovered incidentally. More than one aetiological mechanism is probably involved in the
development of mesenteric cysts. Mesenteric cysts have been reported from the duodenum to
the rectal mesentery but are most commonly located in the ileal mesentery. Malignant cysts
occur in less than 3% of cases. Enucleation of the cyst is the treatment of choice. Knowledge
of these tumours is important due to the various complications associated with suboptimal
surgical management.[8]

A mesenteric cyst is defined as any cyst located in the mesentery, it may or may not extend
into the retroperitoneum, which has a recognizable lining of endthelium or mesothelial cell.
Mesenteric cyst can occur anywhere in the mesentery of gastrointestinal tract from duodenum
to rectum. [7]

Mesenteric cyst may occur in patients of any age. Approximately one-third of cases occur in
children younger than 15 years. The cyst may present either as non specific abdominal
feature, as an incidental finding, or as an acute abdomen. They are often asymtomatic and
found incidentally while patients are undergoig work-up or receiving treatment for other
conditions, such as appendicitis , small bowel obstruction or diverticulitis, although patients
may present with lower abdominal pain and symptoms that are frequently associated with
other abdominal conditions. The symptoms are variable and non spesific and include pain
(82%), nausea and vomiting (45%), constipation (27%), and diarrhoea (6%).[6]

Mesenteric cyst should be evaluated with complete history, clinical examination, blood
investigations, and radiological investigations (X-ray abdomen erect, Ultrasound abdomen
(USG) and Computed Tomography (CT) scan in selected cases) to reach a provisional
diagnostic. The diagnostic is proven on laparotomy and has to be histologically confirmed.
Secondary complications associated with mesenteric cyst include volvulus, spillage of
infective fluid, herniation of bowel into an abdominal defect, and obstruction.[5]

A volvulus is a subtype of malrotation, in which a loop of bowel is twisted about a focal point
along the mesentery attached to the intestinal tract, that may result in a bowel obstruction.[1]

A volvulus is a twisting or axial rotation of a portion of bowel about its mesentery.[3]

Regardless of cause, volvulus causes symptoms by two mechanisms:

Bowel obstruction manifested as abdominal distension and bilious vomiting.

Ischemia (loss of blood flow) to the affected portion of intestine.

Depending on the location of the volvulus, symptoms may vary. For example, in patients
with a cecal volvulus, the predominant symptoms may be those of a small bowel obstruction
(nausea, vomiting and lack of stool or flatus), because the obstructing point is close to the
ileocecal valve and small intestine. In patients with a sigmoid volvulus, although abdominal
pain may be present, symptoms of constipation may be more prominent.

Volvulus causes severe pain and progressive injury to the intestinal wall, with accumulation
of gas and fluid in the portion of the bowel obstructed.[2] Ultimately, this can result in
necrosis of the affected intestinal wall, acidosis, and death. This is known as a closed loop
obstruction because there exists an isolated ("closed") loop of bowel. Acute volvulus often
requires immediate surgical intervention to untwist the affected segment of bowel and
possibly resect any unsalvageable portion.[2]

Volvulus occurs most frequently in middle-aged and elderly men.[2] Volvulus can also arise
as a rare complication in persons with redundant colon, a normal anatomic variation resulting
in extra colonic loops.[4]

Sigmoid volvulus is the most-common form of volvulus of the gastrointestinal tract and is
responsible for 8% of all intestinal obstructions. Sigmoid volvulus is particularly common in
elderly persons and constipated patients. Patients experience abdominal pain, distension, and
absolute constipation.

Small bowel volvulus is an uncommon but important cause of small intestinal obstruction.
Delay in diagnosis and surgical intervention increases morbidity and mortality rates. Based
on cause, small bowel volvulus can be divided into primary and secondary type. Two types of
volvulus are described: 1) primary small intestinal volvulus where no predisposing factors
exist, and 2) secondary volvulus where congenital or acquired conditions promote twisting of
the small intestine. Goals for treatment of small bowel volvulus should include physician
awareness of this uncommon diagnosis, accurate workup and advance surgical intervention.
The resultant mortality rate, however, makes diagnosis critically important. The cardinal
presenting symptom is abdominal pain. There is no single specific diagnostic clinical sign or
laparatomy. The failure to perform an exploratory laparotomy cannot be justified. Early
diagnostic and early surgery are the keys for successful management of strangulation
obstruction of the small bowel.
Conclusion

Mesenteric cyst is one of the rarest abdominal tumours. The cyst may present either as non
specific abdominal feature, as an incidental finding, or as an acute abdomen. Secondary
complications associated with mesenteric cyst include volvulus, spillage of infective fluid,
herniation of bowel into an abdominal defect, and obstruction. Small bowel volvulus is an
uncommon but important cause of small intestinal obstruction. Goals for treatment of small
bowel volvulus should include physician awareness of this uncommon diagnosis, accurate
workup and advance surgical intervention. Early diagnostic and early surgery are the keys for
successful management of strangulation obstruction of the small bowel.
Reference

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