Costal Margin Research Articles

P1036: VOLUMETRIC SPLENOMEGALY IN PATIENTS WITH POLYCYTHEMIA VERA

Background: At present, palpable splenomegaly is relatively uncommon in patients with polycythemia vera (PV), possibly because of early diagnosis facilitated by a lowering of the diagnostic thresholds for hemoglobin and hematocrit levels as well as the wide application of driver gene mutation tests. Radiological volumetric analysis of spleen size is now readily available. However, non-palpable splenomegaly in patients with PV has seldom been addressed. Aims: In this retrospective study, we evaluated non-palpable, volumetric splenomegaly defined based on age- and body surface area (BSA)–matched criteria in patients with PV diagnosed according to the 2016 World Health Organization diagnostic criteria. Methods: Patients with PV who underwent abdominal computed tomography (CT) and who had palpable splenomegaly at diagnosis from January 1991 to December 2020 at Chungnam National University Hospital were enrolled in the study. The spleen volume of each patient was determined by volumetric analysis of abdominal CT and adjusted for the patient’s age and BSA. And then the degree of splenomegaly was classified as follows: no splenomegaly, spleen volume less than the mean plus 2 SD of the reference volume based on both age and BSA; overt volumetric splenomegaly, spleen volume greater than the mean plus 3 SD of the reference volume based on both age and BSA; borderline volumetric splenomegaly, a spleen volume between no splenomegaly and overt splenomegaly; or palpable splenomegaly, spleen palpable below the left costal margin. Results: Of the 87 PV patients enrolled in the study, 15 (17.2%) had no splenomegaly, whereas 17 (19.5%), 45 (51.7%), and 10 (11.5%) had borderline volumetric, overt volumetric, and palpable splenomegaly, respectively. Spleen volume was significantly positively correlated with lactate dehydrogenase level (r = 0.227, P = 0.042) and tended to be positively related to white blood cell count (r = 0.209, P = 0.055) and monocyte count (r = 0.210, P = 0.059) at diagnosis. Spleen volume was not correlated with hemoglobin level, platelet count, or JAK2V617F burden at diagnosis. The degree of splenomegaly did not affect the cumulative incidence of thrombotic vascular events (10-year incidence: 7.7%, 0%, 22.3%, and 50.7%, respectively, P = 0.414). By contrast, splenomegaly tended to adversely affect myelofibrotic transformation (10-year cumulative incidence: 0%, 0%, 7.1%, and 30.3%, respectively, P = 0.062). Moreover, the cumulative incidence of myelofibrotic transformation was significantly higher in patients with overt volumetric or palpable splenomegaly than those with no or borderline volumetric splenomegaly (10-year incidence: 0% vs. 10.3%, respectively; 15-year incidence: 0% vs. 26.3%, respectively, P = 0.020). Overall survival (OS) differed among patients with different degrees of splenomegaly (15-year OS: 100%, 78.6%, 71.7%, and 51.9%, respectively, P = 0.021). The degree of splenomegaly was independent risk factor for both myelofibrotic transformation (hazard ratio [HR]: 7.75; 95% confidence interval [CI]: 1.87-21.10; P = 0.005) and OS (HR: 6.70; 95% CI: 1.89-23.72; P = 0.003). Summary/Conclusion: The degree of splenomegaly, including volumetric splenomegaly, based on age- and BSA-matched reference spleen volumes at diagnosis reflects disease progression in PV patients. Therefore, volumetric splenomegaly should be evaluated at the time of PV diagnosis and taken into consideration when predicting the prognosis of patients with this disorder.

A RARE COMPLICATION OF THE OPERATED STOMACH DISEASE WITH THE FORMATION OF AN EXTERNAL GASTRIC FISTULA

Summary. Stomach and duodenum ulcer occupies a leading place among the surgical diseases of the digestive organs (6–10 % of the population). Operated stomach diseases can be occurred in operated patients as a complication of resections (up to 35 % of cases), and often requires timely diagnosis and repeated invasive reconstructions of the gastrointestinal tract. The aim of the research is to present a clinical case of patient with an atypical course of the operated stomach disease and to highlight the main stages of the diagnostic and treatment algorithm.
 Materials and methods. Analysis of medical publications for the last 5 years, devoted to the clinic, diagnosis and treatment of the operated stomach disease, and analysis of a clinical case of a patient with a rare complication of this pathology.
 Results and discussion. The presented patient underwent Billroth II stomach resection for duodenum peptic ulcer in 2016. In 2021, a left chest wall fistula with suppuration appeared. According to the examination in the hospital (contrast fistulography followed by fibroesophagogastroscopy), the penetration of the stomach stump peptic ulcer into the left costal rib arch with the formation of an external gastric fistula was discover. The patient was operated on using «Laparotomy, stomach resection followed by end-to-end gastroenteroanastomosis reconstruction, Roux entero-enteroanastomosis» with simultaneous excision of the left costal rib arch fistula. In the postoperative period, the wounds healed per prima. The patient was discharged in satisfactory condition.
 Conclusions. The presented case is a casuistic rare complication of the operated stomach disease. Contrast fistulography followed by fibroesophagogastroscopy is useful to establish the cause of the fistula, which is an indication for repeated reconstructive surgery on the stomach stump and gastroenteroanastomosis with excision of the rib arch fistula. To prevent this complication, we recommend scheduled fibroesophagogastroscopy once a year.

Neonatal ventricular assist device implantation for high-risk hypoplastic left heart syndrome: How we do it.

Neonatal ventricular assist device implantation for high-risk hypoplastic left heart syndrome: How we do it.

Fatigue Analysis of Long-Span Steel Truss Arched Bridge Part II: Fatigue Life Assessment of Suspenders Subjected to Dynamic Overloaded Moving Vehicles

In a half-through steel arched bridge, the suspenders are the critical load transfer component that transmits the deck system and traffic load to the arch rib. These suspenders are subjected to traffic and environmental vibrations and are prone to fatigue failure, especially for overloaded moving vehicles. This paper aims to study the impact of moving vehicles’ overloaded rate on the fatigue performance of suspenders in a long-span three steel truss arch bridge. Based on the Mingzhu Bay steel arch bridge, a 3D finite element bridge model was first established and seven types of moving fatigue vehicle models were considered. Then the stress amplitude and dynamic response of the suspenders on the middle steel truss arch were studied under a standard, 25%, and 50% overloaded moving vehicles load. Following that, the Miner fatigue cumulative damage theory was employed to evaluate the fatigue life of the suspenders. The results show that the short suspenders in the middle steel truss arch have the shortest fatigue life but can still meet the design requirements under the standard load. However, the fatigue life of the suspenders decreases by 20% and 30% when the overloading rate reaches 25% and 50%. The fatigue life cannot meet the design requirement when the overload rate is 50%.

Value of assessing liver enlargement as a group a parameter in chronic lymphocytic leukemia (CLL) clinical trials: Retrospective review of data from multiple trials for incidence of liver enlargement and impact on response assessment.

e19517 Background: iwCLL 2018 criteria defines liver enlargement as one of the important group A parameters for staging and overall response assessment (ORA). However, the authors acknowledge that given the impact of numerous medical conditions, liver size by physical examination or CT scan is not a reliable measure of hepatic involvement by CLL and should only be considered if hepatomegaly is clearly attributable to lymphoid involvement. The criteria even define partial response and progression categories as 50% decrease or increase, respectively, but no specific size or other criteria for assessing lymphoid involvement are proposed. Focal lesions in liver may be a sign of involvement by CLL but are assessed separately, as extranodal disease. Hepatomegaly may be non-specific with possible causes including metabolic, infectious, neoplastic, toxic, hereditary, vascular, and miscellaneous other causes. 20-30% of a general population may have non-alcoholic fatty liver enlargement. In the literature hepatomegaly by palpation has been defined as a portion of the liver below the costal margin and the cut-off for normal liver on imaging is considered < 16 cm in mid-clavicular line. However, there are various anatomic variations with no consensus on the size criteria for liver enlargement. Methods: Independent review data from seven phase II/III CLL trials for frontline therapies as well as in relapsed/refractory setting, were retrospectively analyzed. Data included the independent review assessment results of a total of 22224 timepoints (TPs) of 2223 subjects (2223 baseline (BL) and 20001 post-BL TPs). The data were analyzed for the incidence of subjects with liver enlargement at baseline, post-BL assessment of liver and its impact on ORA. Liver assessment in all trials was qualitative, and the criteria for enlargement was based on the reviewer’s judgement; no size limit was defined. Results: Only 7 out of 2223 subjects (0.3%) had liver enlargement at baseline. Liver assessment of these subjects at post-BL did not cause an upgrade or downgrade of the ORA. None of the 2223 subjects had liver progression at post-BL TPs. Conclusions: Based on the data analysis of a large sample size, it is evident that assessment of liver enlargement as a group A parameter in CLL clinical trials, does not impact the ORA. Liver is rarely even assessed as enlarged by independent reviewers, since hepatomegaly may be caused by various other medical conditions besides CLL. No size or other criteria help distinguish between liver enlargement from CLL versus other causes. We recommend removing liver enlargement as a group A parameter for response assessment as it complicates the assessment paradigm without adding any value to it. Liver involvement should only be assessed for focal lesions, as extranodal disease.

BIOMECHANICAL AND PHYSIOLOGICAL PRINCIPLES APPLIED IN CHEST WALL RECONSTRUCTION ASSOCIATED WITH RIB FRACTURES

TYPE: Abstract TOPIC: Cardiothoracic Surgery PURPOSE: The aim of this study was to describe osseointegration of osteosynthesis material and risk of surgical intervention when biomechanical and physiological principles are applied in chest wall reconstruction (CWR). METHODS: All adult patients with pulmonary contusion, multiple rib fractures, flail chest, hemothorax or pneumothorax associated with rib fractures who underwent CWR between March 2012 and December 2016 in emergency department retrospectively included.Titanium clips pressure-fitted at 2 cm proximal and distal were used at each fracture site. Curvature of the clip was made to simulate the natural curvature of the costal arch. In all cases the vascular and nervous package was released. Postoperative follow-ups were obtained from medical records and the integration of the osteosynthesis material was assessed. RESULTS: The 60 patients were 37 men and 23 woman, average age of 44 years. Hospital stays between 7 and 16 days. At 30 days postoperative complications had been recorded such as respiratory insufficiency (n=2) and acute myocardial infarction (n=1).Osteointegration of the osteosynthesis material was found in 59 patients (98.3%) and 1 patient (1.6%) present refracture and mobilization of a titanium implant, for which it was surgery reintervened and the defect corrected CONCLUSIONS: In our study, we found a very high percentage of osseointegration when using the biomechanical principles in the techniques for CWR. CLINICAL IMPLICATIONS: The healing process near fracture sites relies in a correct immobilization,adequate vascularization and formation of bone callus and new bone therefore, by using titanium clips combined with different biomechanical principles they help this purpose by improving the conditions at the fracture site. DISCLOSURE: Nothing to declare. KEYWORD: CHEST WALL RECONSTRUCTION

The correction of the diastasis of the rectus abdominis muscle concomitant with a moulded silicone implant insertion in a patient with medial pectus excavatum.

The association of the diastasis of the rectus abdominis muscle and the medial pectus excavatum was reported. We have been using soft silicone block, sculpted intraoperatively, to correct pectus excavatum. The horizontal access used, 2 cm at a subxiphoid position, allows us to expose the sternum and the rectus abdominis muscles (RAMs). We report a case, male, 31 years presenting medial pectus excavatum and supraumbilical diastasis of the rectus abdominis muscle with a width of 35 mm at the costal arches, and 27 mm at 6 cm from the xiphoid process edge. The muscle borders presented a curved lateral deviation up to the insertion in the costal arches. The necessary space for the implant was dissected and the block was sculpted. The medial and superior aponeurosis borders of the RAM were incised at 6 cm from the xiphoid, and the posterior border of the RAM was released. The aponeurosis borders were brought together, promoting a medial and anterior positioning of the RAM. The inferior border of the implant was attached to the raw superior borders of the RAM. The result was considered satisfactory, and a magnetic resonance image 14 months after showed continuity of the implant and the muscles, promoting a uniform body contour.Registry: CAAE63181616.7.0000.0071.

Adjustable arch-beam combination structural strengthening system for reinforced concrete beam bridge

A new adjustable and combined reinforcement method consisting of arch rib and steel beam is proposed in this paper. The principle is to redistribute the internal forces of the structure through the support of the arch rib and to form a combined structure by using steel and concrete. Symmetrically loaded bending tests were carried out with five different combined strengthening schemes. The analysis of the test process was conducted adopting a FEM model, and the equations for calculating the RC beam's load capacity under combined strengthening were derived while considering the slip effect. The experimental results indicated that the combined reinforcement method had a synergistic effect when the ultimate load capacity had increased by more than 95% after reinforcement. As the size of the arch ribs and profile beams increased, a better reinforcement effect was seen. However, beyond a certain range, the RC beams had already broken down and had failed before the reinforcement material could yield. The combined reinforcement method changes the force system of the original RC beam, resulting in a smaller angular inclination trend of the cracks in the original purely curved section and a smaller crack extension. The non-linear finite element results are generally consistent with experimental loads, displacements, and ductility, while the average ratio of experimental to calculated ultimate Load capacity is 0.95, demonstrating that non-linear finite elements and theoretical formulas are accurate.

Distributed detection of internal cavities in concrete-filled steel tube arch bridge elements

Internal cavities in structural elements, such as in concrete-filled steel tubes (CFSTs) of arch ribs reduce confinement, bearing capacity, and the durability of the arch bridges. Formation of internal cavities may be either materials related, which affects proper consolidation, or construction related, especially in terms of proper timing and delivery of concrete slurry to horizontal and inclined structural members. Nondestructive test methods such as ultrasonics have been employed for detection of internal cavities. Despite their success, point-by-point inspection of structural members becomes time-consuming and inefficient, especially when entire structures need to be inspected. Infrared thermography (IR) provides a more reasonable global approach for detection of anomalies. The accuracy and resolution of IR depend on the local ambient conditions affecting convection and external thermal flux prior to detection by IR. The research described herein pertains to the development of a hybrid thermographic approach by using Brillouin fiber optic sensors (BFOSs) for direct detection of thermal convection at the surfaces of steel tubes. Accurate quantitative detection of internal cavity locations and their dimensions required development of a specific machine learning-based approach through which the distributed thermographic data was converted to a series of grayscale images. A Faster Region-based Convolutional Neural Network (Faster R-CNN) based on the improved VGG-16 (IVGG-16) network architecture was utilized for this purpose. The experimental work involved design and fabrication of a distributed temperature sensing sheet (DTSS) for simultaneous transmission of thermal energy into CFST specimens and acquisition of distributed thermographic data by the BFOS. By using the proposed approach, it was possible to detect the embedded internal cavities during the experiments.

Clinical features and prognosis of childhood B-lineage acute lymphoblastic leukemia expressing the PRAME gene

To study the clinical and prognostic significance of the preferentially expressed antigen of melanoma (PRAME) gene in the absence of specific fusion gene expression in children with B-lineage acute lymphoblastic leukemia (B-ALL). A total of 167 children newly diagnosed with B-ALL were enrolled, among whom 70 were positive for the PRAME gene and 97 were negative. None of the children were positive for MLL-r, BCR/ABL, E2A/PBX1, or ETV6/RUNX1. The PRAME positive and negative groups were analyzed in terms of clinical features, prognosis, and related prognostic factors. Compared with the PRAME negative group, the PRAME positive group had a significantly higher proportion of children with the liver extending >6 cm below the costal margin (P<0.05). There was a significant reduction in the PRAME copy number after induction chemotherapy (P<0.05). In the minimal residual disease (MRD) positive group after induction chemotherapy, the PRAME copy number was not correlated with the MRD level (P>0.05). In the MRD negative group, there was also no correlation between them (P>0.05). The PRAME positive group had a significantly higher 4-year event-free survival rate than the PRAME negative group (87.5%±4.6% vs 73.5%±4.6%, P<0.05), while there was no significant difference between the two groups in the 4-year overall survival rate (88.0%±4.4% vs 85.3%±3.8%, P>0.05). The Cox proportional-hazards regression model analysis showed that positive PRAME expression was a protective factor for event-free survival rate in children with B-ALL (P<0.05). Although the PRAME gene cannot be monitored as MRD, overexpression of PRAME suggests a good prognosis in B-ALL.

Seismic response of the long-span steel truss arch bridge with the thrust under multidimensional excitation

PurposeUnder different ground motion excitation modes, the spatial coupling effect of seismic response for the arch bridge with thrust, seismic weak parts and the internal force components of the control section of main arch ribs are analyzed.Design/methodology/approachTaking a 490 m deck type railway steel truss arch bridge as the background, the dynamic calculation model of the whole bridge was established by SAP2000 software. The seismic response analyses under one-, two- and three-dimension (1D, 2D and 3D) uniform ground motion excitations were carried out.FindingsFor the steel truss arch bridge composed of multiple arch ribs, any single direction ground motion excitation will cause large axial force in the chord of arch rib. The axial force caused by transverse and vertical ground motion excitation in the chord of arch crown area is 1.4–3.6 times of the corresponding axial force under longitudinal seismic excitation. The in-plane bending moment caused by the lower chord at the vault is 4.2–5.5 times of the corresponding bending moment under the longitudinal seismic excitation. For the bottom chord of arch rib, the arch foot is the weak part of earthquake resistance, but for the upper chord of arch rib, the arch foot, arch crown and the intersection of column and upper chord can all be the potential earthquake-resistant weak parts. The normal stress of the bottom chord of the arch rib under multidimensional excitation is mainly caused by the axial force, but the normal stress of the upper chord of the arch rib is caused by the axial force, in-plane and out of plane bending moment.Originality/valueThe research provides specific suggestions for ground motion excitation mode and also provides reference information for the earthquake-resistant weak part and seismic design of long-span deck type railway steel truss arch bridges.

Myeloproliferative neoplasms – a global view

Myeloproliferative neoplasms – a global view

Wind-Induced Response Analysis for a Fatigue-Prone Asymmetric Steel Arch Bridge with Inclined Arch Ribs

Steel arch bridges with inclined arch ribs under strong wind fields are prone to fatigue damage due to the stress concentration at the position of hanger connections. Therefore, it is essential to perform the wind-induced response analysis for specified shape hangers, such as inclined hangers, to determine the stress distribution and corresponding influencing factors. In this study, wind-induced response analysis for a fatigue-prone asymmetric steel arch bridge with inclined arch ribs is performed by the numerical simulation approach. The investigated bridge hangers’ models are established by using the COMSOL Multiphysics software. The wind-induced stress of the bridge hangers under different wind directions is obtained based on the finite element method. The influential factor of the stress distribution of the bridge hangers on both the windward side and the leeward side is discussed. In addition, the stress peaks of the long hanger and short hanger are achieved for further fatigue analysis. This paper provides a reference for determining the critical fatigue-prone position of an asymmetric steel arch bridge with inclined arch ribs.

Assessing Respiratory Activity by Using IMUs: Modeling and Validation.

This study aimed to explore novel inertial measurement unit (IMU)-based strategies to estimate respiratory parameters in healthy adults lying on a bed while breathing normally. During the experimental sessions, the kinematics of the chest wall were contemporaneously collected through both a network of 9 IMUs and a set of 45 uniformly distributed reflective markers. All inertial kinematics were analyzed to identify a minimum set of signals and IMUs whose linear combination best matched the tidal volume measured by optoelectronic plethysmography. The resulting models were finally tuned and validated through a leave-one-out cross-validation approach to assess the extent to which they could accurately estimate a set of respiratory parameters related to three trunk compartments. The adopted methodological approach allowed us to identify two different models. The first, referred to as Model 1, relies on the 3D acceleration measured by three IMUs located on the abdominal compartment and on the lower costal margin. The second, referred to as Model 2, relies on only one component of the acceleration measured by two IMUs located on the abdominal compartment. Both models can accurately estimate the respiratory rate (relative error < 1.5%). Conversely, the duration of the respiratory phases and the tidal volume can be more accurately assessed by Model 2 (relative error < 5%) and Model 1 (relative error < 5%), respectively. We further discuss possible approaches to overcome limitations and improve the overall accuracy of the proposed approach.

Comparison of ultrasound-guided transversus abdominis plane (TAP) block and quadratus lumborum (QL) block in inguinal hernia surgery.

Comparison of ultrasound-guided transversus abdominis plane (TAP) block and quadratus lumborum (QL) block in inguinal hernia surgery.

Changes in bone marrow and peripheral blood lymphocyte subset findings with onset of hepatitis-associated aplastic anemia.

Rationale:Hepatitis-associated aplastic anemia (HAAA) is a rare illness that results in bone marrow failure following hepatitis development. The etiological agent remains unknown in most HAAA cases. However, clinical features of the disease and immunotherapy response indicate that immune-mediated factors play a central role in the pathogenesis of HAAA. Activation of cytotoxic T cells and increase in CD8 cells could exert cytotoxic effects on the myelopoietic cells in the bone marrow.Patient concerns:A 15-month-old boy was brought to our hospital with complaints of generalized petechiae and purpura observed a week prior to hospitalization. His liver was palpated 3 cm below the costal margin, platelet count was 0 × 104/μL, and alanine aminotransferase level was 1346 IU/L. A blood test indicated cytomegalovirus infection, and 3 bone marrow examinations revealed progressive HAAA. As the disease progressed to the 3rd, 6th, and 9th week after onset, CD4+ T cells were markedly decreased, CD8+ T cells were markedly increased, and the CD4/CD8 ratio was significantly decreased. The number of B cells and natural killer cells decreased with time, eventually reaching 0.0%.Diagnosis:HAAA.Interventions:Rabbit antithymocyte globulin and eltrombopag olamine (a thrombopoietin receptor agonist) were administered.Outcomes:The patient's platelet count returned to normal, and bone marrow transplantation was avoided. The peripheral blood lymphocytes (PBLs) improved as the patient's general condition recovered.Lessons:This case demonstrates that HAAA induced by cytomegalovirus infection features decreasing CD4+ and increasing CD8+ PBLs as the bone marrow hypoplasia progresses. The PBLs return to their normal levels with the recovery from the disease. Our case findings thus support the involvement of immunological abnormality in HAAA.

The first maguviopseids (Hemiptera, Cicadomorpha, Prosboloidea) from the Triassic of China

The extinct hemipteran superfamily Prosboloidea Handlirsch, 1906 comprises two ancient families (viz., Prosbolidae Handlirsch, 1906 and Maguviopseidae Shcherbakov, 2011) reported from the Permian (Artinskian) to the Jurassic (Callovian) (Szwedo, 2018). The Triassic family Maguviopseidae was established by Shcherbakov (2011) with relatively high generic diversity, including eleven genera within two subfamilies: Sacvoyageinae Shcherbakov, 2011; and Maguviopseinae Shcherbakov, 2011 comprising two tribes, occurring from the Middle to Upper Triassic Madygen Formation of Madygen, Kyrgyzstan. The known maguviopseids show diversified tegminal shapes with sculptured ornamentations on surface, and some genera with highly convex costal margin are considered as an adaptative to mimicry among their hostplants (probably seeds or buds) in order to avoid predators (Shcherbakov, 2011).

Experimental Study on Bearing Capacity of Corroded Reinforced Concrete Arch Considering Material Degradation

To study the bearing capacity of a corroded reinforced concrete (RC) arch and analyze the deterioration mechanism of an in-service RC arch bridge, a deterioration simulation under the coupling effect of the environment and load was performed by employing non-immersion energization, and considering the dead load on the arch, single point loading tests of the arch models were carried out; the crack development, structural deformation, and ultimate bearing capacity of a corroded RC arch under service stress were studied; the failure mode of the corroded arch was explored; and a bearing capacity prediction model considering dual deterioration effects of reinforcement corrosion deterioration and arch axis deterioration was established. Results indicated that the spacing of cracks caused by a load on the non-corroded arch was more uniform, and the number and distribution range of load-induced cracks in the corroded arch was smaller, while the maximum crack width was larger. Corrosion significantly reduced the strength of the arch rib; for the deteriorated arch with a corrosion rate of 7.62%, the cracking load and the bearing capacity decreased by 28.57 and 9.84%, respectively. Corrosion weakened structural stiffness, while it does not convert the failure mode of the arch. Only considering section resistance degradation may underestimate the damaging effects of corrosion on the arch structure.

A Male Infant with Cholestatic Jaundice, Hemolytic Anemia, and Thrombocytopenia.

A Male Infant with Cholestatic Jaundice, Hemolytic Anemia, and Thrombocytopenia.

English

A 15-year-old female patient came with complaint of pain in the left hypochondriac region from past 2 months, which was dull aching, intermittent, aggravated on taking deep breaths, and relieved at rest. Patient also gave history of early satiety. No history of trauma, vomiting, altered bowel habits, fever, night sweats, and weight loss. The patient denied history of any recent travel. On physical examination, a firm nontender mass of size 20×15 cm was palpated in the left hypochondriac region extending to the epigastric, umbilical and left lumbar region with medial border at 5cm right lateral to the umbilicus and finger insinuation was not possible below the left costal margin. The patient underwent ultrasound abdomen which showed large well defined cystic lesion measuring 20X19X30cm, volume 5000-5700cc occupying the left hypochondrium, lumbar, epigastric and umbilical regions with irregular trabeculated wall and internal echoes within. It was seen causing mass effect in the form of posterior displacement of bilateral kidneys, spleen and inferior displacement of bowel loops. Features were suggestive of probable large mesenteric cyst. Computed tomography (CT) of abdomen and pelvis with oral and intravenous contrast was done which showed a large thin-walled abdominal cystic lesion measuring 19x18x22cm of volume approximately 3500- 4000cc occupying the left hypochondrium, epigastric region, umbilical region, reaching up to the lumbar region. It was seen arising from spleen with thinned out splenic parenchyma along its superior, lateral and inferior aspect (claw sign). Anteriorly it was extending to the anterior abdominal wall and abutting the recti muscles. Mass effect was noted on liver and right kidney with displacement of the organs (Figure 1: a, b).