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Intraperitoneal cysts in infancy
and childhood “An overview and sonographic
differentiation”
M. Mearadji
International Foundation for
Pediatric Imaging Aid
Rotterdam, The Netherlands
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Intraperitoneal cysts
In general, intraperitoneal cysts can be categorized in
3 groups:
I. Ovarial cysts mostly observed in the postnatal
period or later life.
II. Lymphogenic cysts including, mesenterial,
omental as well as lymphangiomatous cysts
elsewhere intra- or retroperitoneal.
III. Esophagogastro-intestinal duplication cysts.
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Patient material
• 67 cases were reviewed.
• The characteristic sonographic findings
of different cystic lesions were analyzed
with an attempt to differentiate them
from each other in relation to their organ
of origin.
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I. Ovarian cysts
• Cysts account for most ovarian masses in infants and children.
• Sonography can afford an accurate assessment of the presence, size, location and internal echogenicity of an ovarian mass.
• Depending on the age the ovarian cysts should be devided in: – Neonatal cysts
– Functional cysts, postmenarchal in girls
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Neonatal ovarian cysts
• Results from exaggeration of the normal
follicular development secondary to excessive
maternal hormonal stimulation in the utero.
• May be an incidental finding on sonography or
symptomatic with abdominal distention.
• An uncomplicated neonatal ovarian cyst
resolves mostly spontaneously within the first 5
– 6 months.
• An adnexal torsion is often a common
complication of ovarian cyst.
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Patient material: neonatal ovarian cyst (n=26)
• Uncomplicated neonatal ovarian cysts were resolved spontaneously in 9 cases.
• Complication following torsion or hemorrhage were found in 10 cases.
• Surgical resection was performed in 17 cases with complicated and unresolved cysts.
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Sonographic findings
The simple uncomplicated neonatal ovarian cyst was
usually unilocular and has anechoic content with an
imperceptible wall. Occasionally a thin septation was
observed.
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Sonographic findings
The complicated cysts were frequently septated,
occasionally with a retracting clot or fluid-debris and
often with an echogenic wall.
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Sonographic findings
A few huge cysts were extended to the upper
abdomen.
2 cases of uncomplicated large ovarian cysts.
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Postmenarchal functional cysts
• Result of continuous growing of follicle after failed ovulation or if corpus luteum fails to involate after ovulation.
• Pathologic if the diameter of the cyst exceeds the limit of 3 cm.
• Ovarian cysts in adolescent girls can be symptomatic or asymptomatic.
• Our patient material includes only four uncomplicated postmenarchal ovarian cysts.
• The cysts were all anechoic, thin walled and unilocular. Our material includes one case of McCune Albright syndrome with precocious puberty.
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Postmenarchal ovarian cyst Ovarian cyst by McCune
Albright syndrome
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II. Lymphogenic cysts
• Caused by sequestration or obstruction of
lymphatic vessels.
• Anatomical manifestion as mesenteric,
omental, or as intra- or retroperitoneal cysts.
• The fluid content is primarily chylus but may
contain hemorrhage.
• The patients usually come to medical
attention because of an abdominal mass with
or without abdominal pain.
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Patient material (n=16)
The reviewed patient material included:
• 5 mesenterial cysts
• 4 omental cyst
• 7 intra- or retroperitoneal cysts
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Sonographic findings
• Mesenteric cysts were mostly multilocular and
anechoic with variable extension.
• Omentum cysts were located in a typical
position, anechoic and monolocular.
• The cysts in other locations were anechoic,
mostly retroperitoneal. Some of them were
located intraperitoneally with a little increased
echogenicity.
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3 different cases of
mesenterial cysts
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2 different cases of
omental cyst
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A case with intraperitoneal cystic lymphangiomatosis
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A case of retroperitoneal
cystic lymphangioma
localized in the lower pole of
the left kidney.
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III. Esophagogastro-intestinal
duplication
• Result of multiple twinning, persistent embryologic
diverticula or aberrant luminal recanalisation.
• Mostly no communication with the normal developed
parts of the GI canal.
• Clinical signs and symptoms include abdominal pain,
palpable mass, vomiting and rectal bleeding.
• May be a lead point for intussusception.
• May contain ectopic gastric mucousa, lymphaoid
aggregates, ganglion cell and lymphatic tissue.
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Patient material (n=25)
The reviewed cases included:
• 3 esophageal duplication cysts
• 1 gastric duplication cyst
• 3 colonic duplication cysts
• 18 enteric duplication cysts, mostly
located in the ileum (5 of them were
communicating duplication cysts)
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Sonographic findings
• Well defined spherical or tubular fluid-filled masses in case of uncommunicated cysts.
• Heterogenic appearance with debris and/or septation following complication.
• The cyst wall contains all normal bowel layers including mucosal, submucosal and muscularis.
• The muscular layer is typically shared with adjacent bowel wall but the mucosal layer is separated.
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Esophageal duplication cyst
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Cystic duplication of the stomach
with hypertrophic pylorus stenosis
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Cystic duplication of the
duodenum
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Communicated
duplication of
jejunum
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Duplication cyst of coecum
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Non communicating
ileum duplication
Non communicating ileum
duplication with meconium
peritonits
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Uncomplicated ileum duplication with increased echogenicity
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Conclusions Ovarian cyst
• The high incidence of ovarian cysts in girls is an indication to look primarily for topographic relation of all cysts with the pelvic organs.
• Debris, septation and thickening of the cystic wall are sonographic signs of complicated ovarial cysts.
• In neonates ovarian cysts mostly resolve spontaneously. Therefore sonographic follow up and an expectative policy in treatment is indicated.
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Conclusions Lymphogenic cysts
• Uncomplicated mesenterial cysts are
variable in size, thin walled, multiseptated
and anechoic.
• Mesenteric cysts are located anywhere
but have no anatomic relation to the pelvic
organs.
• Debris and internal septation with or
without wall thickening are signs of
complication of lymphogenic cysts.
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Conclusions Duplication cysts
• Enteric duplication cysts manifest frequently as a non-communicating cysts and rarely as a communicating cyst.
• Enteric duplication cysts are mostly spherical or tubular fluid filled masses with incidentally peristaltic activity.
• The combination of echogenic (mucus) and hypoechoic (muscle) are specific signs of duplication cysts.
• A large and complicated duplication is mostly thin walled without mucosal layers.