Neonatal Pseudoascites: An Unusual Presentation of Long Tubular Duplication of Small Bowel By Dilip M. Purohit, Clifford A. Lakin, and H. Biemann Othersen, Jr, Charles ton, South Carolina 0 This is a case report of a tubular duplication with a clinical presentation as pseudoascites. It was treated surgically by stripping its mucosel lining. INDEX WORD: Intestinal duplication.
D UPLICATIONS
OF THE
gastrointestinal
in the small bowel especially in the ileum.‘-’ They are generally located on the mesenteric border lying between the leaves of the mesentry, underneath the mesenteric vessels. Spherical duplications are usually localized, noncommunicating cystic structure$ whereas tubular duplications vary in length, often communicate with the normal bowel proximally and/or distally, and frequently contain gastric mucosa.4’5 A common muscular wall usually exists between the duplication and the normal bowel throughout at least part of its length.‘**s4 Due to ectopic acid secreting mucosa, tubular duplication of the bowel usually presents with bleeding and rarely with perforation secondary to peptic ulceration.3*8 Spherical duplication may serve as a leading point for intussusception and a distended duplicated segment may cause intestinal obstruction.4,5 Occasionally, duplication may be completely asymptomatic only to be discovered during operation for other intra-abdominal problems or at autopsy.4*s In the neonatal period, duplication may also present as a palpable mass in the right lower quadrant.2*4 This unusual case of cystic duplication of small bowel is being reported because of its clinical presentation as pseudoascites9 and the surgical approach of stripping of the mucosal lining of the duplication.6.‘0 tract occur most frequently
examination of the infant on admission revealed a soft distended abdomen with patulous, bulging flanks (Fig. 2). Paracentesis was performed with removal of 200 ml of clear yellow fluid of the following composition: protein 0.5 g/ 100 ml, albumin 0.36 g/100 ml, total cells 84/mm’, mesothelial cells 34%. polymorphs 29%, lymphocytes 37%, RBC 4%, sodium 139 mEq/L, potassium 3.5 mEq/L, chlorides 106 mEq/L, urea nitrogen 12 mg/lOO ml, and glucose 42 mg/lOO ml. The serum electrolytes were normal. Roentgenogram of the abdomen revealed densities in both flanks that seemed to displace distended loops of bowels centrally and
Fig. 1. Intravenouspyelogramshowingnormalurinary tract with suggestion of an intra-abdominal soft tiSSu8 density.
CASE REPORT A 3671-g, term, white male infant was born in a local hospital with an Apgar score of 3 and 5 at 1 and 5 min, respectively. Abdominal distention with a girth of 43 cm was noticed at birth and paracentesis yielded 600 ml of straw colored fluid. A portal venogram performed via an umbilical -venous catheter at 2 days of age was normal. An intravenous pyelogram showed a normal urinary tract with a suggestion of an intra-abdominal soft tissue density (Fig. 1). Physical
Journal of Pediatric Surgery, Vol. 14. No. 2 (April), 1979
From the Departments of Pediatrics and Surgery, Medical University of South Carolina, Charleston, S.C. Address reprint requests lo H. Biemann Othersen, Jr., M.D.. Projessor of Surgery and Pediatrics., Medical Vniversity of South Carolina, I71 Ashley Avenue, Charleston, S.C. 29403 01979 by Grune & Stratton, Inc. 0022-3468/79/1402-0021$01.00/0
193
194
PUROHIT.
Fig. 3.
Fig. flanks.
2.
Distended
abdomen
with
patulous
Gross appearance
LAKIN.
AND
OTHERSEN
of duplication at operation.
bulging
anteriorly. The ultrasound scan of the abdomen was consistent with either ascites or large flimsy cystic collections of fluids. With a preoperative diagnosis of mesenteric cyst or omental cyst, an exploratory laporotomy was performed on the seventh day of age. At operation, non communicating duplication cyst of the small bowel, 74 cm in length, was found adherent to the distal small bowel, approximately 15 cm from the ileocecal valve (Fig. 3). It shared a common muscular wall with the adjacent bowel on its mesenteric border except for the distal 15 cm. The cecum, elevated by the duplication cyst, was freely mobile. Frozen section of the cyst wall revealed circular and longitudinal muscle coats with neural plexus between lamina propria and mucosa similar to that of the small intestine. After identifying the
ligament of Treitz, the mesenteric border between the normal bowel and the duplication was opened in the midportion of the duplication. However, since the duplication shared a common muscular wall with the adjacent bowel. a plane of dissection could not be found. Therefore, the duplication was incised after making an opening in a relatively avascular area of the overlying mesentery. The mucosa and the submucosa of the duplicated segment were carefully separated from the muscular layer. The duplicated segment contained approximately 500 ml of clear, viscous, yellow tluid. After excision of the inner mucosal tube, the remaining attenuated muscular layer was sutured at its divided edge with the corresponding serosal edge of the normal bowel. The infant did well following the procedure, took oral feedings by the fourth postoperative day and was discharged on the thirteenth hospital day. He was doing well 7 mo postoperatively.
REFERENCES
I. Bramer JL: Diverticula and duplications of the intestinal tract. Arch Path01 38:I 32-140, 1944 2. Houston HE, Lynn HB: Duplications of the small intestine in children: Mayo Clinic experience and review of the literature. Mayo Clin Pro 41:246-256, 1966 3. Jewett TC Jr: Duplication of the entire small intestine with massive melena. Ann Surg 147:239-244, 1958 4. Mellish RWP, Koop CE: Clinical manifestations of duplication of the bowel. Pediatrics 27:397-407, 1961 5. Moore TC, Battersby JS: Congenital duplications of the small intestine. Surg Gynecol Obstet 95:5577567, 1952 6. Mustard WT, Ravitch MM, Snyder WH Jr. et al:
Pediatric Surgery 1969, pp 836-838
(ed) Yearbook
7. Ripstein CB: Duplication Surg 78847-852, 1962
Medical
Publishers,
of the small intestine.
8. Stagg PA, Lynn HB: Perforated Am Surg 24:415-417, 1958
duplication
9. Caffey J: Pediatric X-ray Diagnosis Chicago, Year Book Medical Publishers, 1537 IO. Wrenn EL Jr: Tubular duplication tine. Surgery 52:494-498, 1962
Inc. Am J
of ileum.
(ed) Volume 2, Inc., pp 1533.of the small intes-
D UPLICATIONS
OF THE
gastrointestinal
in the small bowel especially in the ileum.‘-’ They are generally located on the mesenteric border lying between the leaves of the mesentry, underneath the mesenteric vessels. Spherical duplications are usually localized, noncommunicating cystic structure$ whereas tubular duplications vary in length, often communicate with the normal bowel proximally and/or distally, and frequently contain gastric mucosa.4’5 A common muscular wall usually exists between the duplication and the normal bowel throughout at least part of its length.‘**s4 Due to ectopic acid secreting mucosa, tubular duplication of the bowel usually presents with bleeding and rarely with perforation secondary to peptic ulceration.3*8 Spherical duplication may serve as a leading point for intussusception and a distended duplicated segment may cause intestinal obstruction.4,5 Occasionally, duplication may be completely asymptomatic only to be discovered during operation for other intra-abdominal problems or at autopsy.4*s In the neonatal period, duplication may also present as a palpable mass in the right lower quadrant.2*4 This unusual case of cystic duplication of small bowel is being reported because of its clinical presentation as pseudoascites9 and the surgical approach of stripping of the mucosal lining of the duplication.6.‘0 tract occur most frequently
examination of the infant on admission revealed a soft distended abdomen with patulous, bulging flanks (Fig. 2). Paracentesis was performed with removal of 200 ml of clear yellow fluid of the following composition: protein 0.5 g/ 100 ml, albumin 0.36 g/100 ml, total cells 84/mm’, mesothelial cells 34%. polymorphs 29%, lymphocytes 37%, RBC 4%, sodium 139 mEq/L, potassium 3.5 mEq/L, chlorides 106 mEq/L, urea nitrogen 12 mg/lOO ml, and glucose 42 mg/lOO ml. The serum electrolytes were normal. Roentgenogram of the abdomen revealed densities in both flanks that seemed to displace distended loops of bowels centrally and
Fig. 1. Intravenouspyelogramshowingnormalurinary tract with suggestion of an intra-abdominal soft tiSSu8 density.
CASE REPORT A 3671-g, term, white male infant was born in a local hospital with an Apgar score of 3 and 5 at 1 and 5 min, respectively. Abdominal distention with a girth of 43 cm was noticed at birth and paracentesis yielded 600 ml of straw colored fluid. A portal venogram performed via an umbilical -venous catheter at 2 days of age was normal. An intravenous pyelogram showed a normal urinary tract with a suggestion of an intra-abdominal soft tissue density (Fig. 1). Physical
Journal of Pediatric Surgery, Vol. 14. No. 2 (April), 1979
From the Departments of Pediatrics and Surgery, Medical University of South Carolina, Charleston, S.C. Address reprint requests lo H. Biemann Othersen, Jr., M.D.. Projessor of Surgery and Pediatrics., Medical Vniversity of South Carolina, I71 Ashley Avenue, Charleston, S.C. 29403 01979 by Grune & Stratton, Inc. 0022-3468/79/1402-0021$01.00/0
193
194
PUROHIT.
Fig. 3.
Fig. flanks.
2.
Distended
abdomen
with
patulous
Gross appearance
LAKIN.
AND
OTHERSEN
of duplication at operation.
bulging
anteriorly. The ultrasound scan of the abdomen was consistent with either ascites or large flimsy cystic collections of fluids. With a preoperative diagnosis of mesenteric cyst or omental cyst, an exploratory laporotomy was performed on the seventh day of age. At operation, non communicating duplication cyst of the small bowel, 74 cm in length, was found adherent to the distal small bowel, approximately 15 cm from the ileocecal valve (Fig. 3). It shared a common muscular wall with the adjacent bowel on its mesenteric border except for the distal 15 cm. The cecum, elevated by the duplication cyst, was freely mobile. Frozen section of the cyst wall revealed circular and longitudinal muscle coats with neural plexus between lamina propria and mucosa similar to that of the small intestine. After identifying the
ligament of Treitz, the mesenteric border between the normal bowel and the duplication was opened in the midportion of the duplication. However, since the duplication shared a common muscular wall with the adjacent bowel. a plane of dissection could not be found. Therefore, the duplication was incised after making an opening in a relatively avascular area of the overlying mesentery. The mucosa and the submucosa of the duplicated segment were carefully separated from the muscular layer. The duplicated segment contained approximately 500 ml of clear, viscous, yellow tluid. After excision of the inner mucosal tube, the remaining attenuated muscular layer was sutured at its divided edge with the corresponding serosal edge of the normal bowel. The infant did well following the procedure, took oral feedings by the fourth postoperative day and was discharged on the thirteenth hospital day. He was doing well 7 mo postoperatively.
REFERENCES
I. Bramer JL: Diverticula and duplications of the intestinal tract. Arch Path01 38:I 32-140, 1944 2. Houston HE, Lynn HB: Duplications of the small intestine in children: Mayo Clinic experience and review of the literature. Mayo Clin Pro 41:246-256, 1966 3. Jewett TC Jr: Duplication of the entire small intestine with massive melena. Ann Surg 147:239-244, 1958 4. Mellish RWP, Koop CE: Clinical manifestations of duplication of the bowel. Pediatrics 27:397-407, 1961 5. Moore TC, Battersby JS: Congenital duplications of the small intestine. Surg Gynecol Obstet 95:5577567, 1952 6. Mustard WT, Ravitch MM, Snyder WH Jr. et al:
Pediatric Surgery 1969, pp 836-838
(ed) Yearbook
7. Ripstein CB: Duplication Surg 78847-852, 1962
Medical
Publishers,
of the small intestine.
8. Stagg PA, Lynn HB: Perforated Am Surg 24:415-417, 1958
duplication
9. Caffey J: Pediatric X-ray Diagnosis Chicago, Year Book Medical Publishers, 1537 IO. Wrenn EL Jr: Tubular duplication tine. Surgery 52:494-498, 1962
Inc. Am J
of ileum.
(ed) Volume 2, Inc., pp 1533.of the small intes-
