Mesenteric cystic lymphangioma in adults: a rare entity presenting as acute abdomen - a report of two cases

Abstract

Lymphangiomas are rare benign tumors that mainly involve the head and neck region in pediatric patients. Lymphangiomas of the small bowel mesentery in adults are rarer. We present two cases of mesenteric lymphangioma with acute abdominal pain on presentation. Case 1: A 38-year-old female presented with abdominal pain, vomiting, fever, and difficult evacuation. On abdominal examination, she had an ill-defined, tender lump, and radiological findings raised a possibility of perforation peritonitis. Thus, exploratory laparotomy was planned. Per-operatively, a mesenteric mass was found, which, on histopathological evaluation, was found to be a mesenteric lymphangioma involving the bowel. Case 2: A 27-year-old male presented with abdominal pain and difficult evacuation. Radiological evaluation revealed a multilobulated lesion involving the mesentery and with differential diagnoses of mesenteric fibromatoses and inflammatory pseudotumor. Histopathological assessment of the resected mass revealed a lymphangioma that was limited to the mesentery. Owing to their rarity and non-specific presentation, mesenteric lymphangiomas are often misdiagnosed on clinical examination and imaging. Thus, histopathological examination is the gold standard to reach a definitive diagnosis.

Keywords: Abdomen, Acute; Adult; Lymphangioma; Lymphatics; Mesentery.

Figure 1. A - A plain abdominal radiograph revealing ground glass appearance with multiple air fluid levels in the abdomen; B - Gross specimen of small intestine with large cystic mesenteric mass encroaching the serosal surface of ileum and comprising of cysts containing milky fluid. (scale bar=10 cm); C and D - Photomicrographs of the surgical specimen; C - Variable sized dilated lymphatic channels lined by flattened endothelium within the mesenteric mass; and D - in the serosa (H&E, 400x).

Figure 2. A and B - Photomicrographs of the surgical specimen showing mature adipose tissue interspersed with variable-sized, dilated lymphatic channels within the mucosa, submucosa, and muscularis propria (H&E, 400x); C - CD31 positive lymphatic channels in the mesenteric mass (CD31, 400x).

Figure 3. A - Gross specimen of large mesenteric mass with multiple tiny cysts and areas of vascular congestion. (scale bar= 4 cm); B - Variable-sized, thin-walled, dilated lymphatic channels lined by flattened endothelium (H&E, 400x); C - Dilated lymphatic channels with focal surrounding lymphoid aggregates (H&E, 400x).

Figure 4. Photomicrographs of surgical sections stained with immunohistochemistry. A - D2-40 positive endothelial cells lining the lymphatic channels (200x); B - CD31 positive endothelial cells lining the lymphatic channels (200x).