Mesenteric Disease Research Articles

Chronic Mesenteric Ischemia in a 26-Year-Old Man: Multivessel Median Arcuate Ligament Compression Syndrome

Chronic mesenteric ischemia (CMI) is a rare diagnosis for patients in their third decade of life. Other conditions can mimic the signs and symptoms of CMI, including median arcuate ligament syndrome (MALS), primary arteritides, and congenital anomalies. Here, we present the case of a 26-year-old man who presented with CMI and multivessel mesenteric occlusive disease. A 26-year-old man presented with a 6-month history of 40-pound weight loss, postprandial abdominal pain, and food fear. His physical examination showed a scaphoid abdomen with no tenderness. Findings from laboratory evaluation were normal. Computed tomography angiogram revealed celiac artery (CA) occlusion and >80% superior mesenteric artery (SMA) stenosis, with a large marginal artery of Drummond supplying collateral circulation. A retroperitoneal exposure of the perivisceral aorta was performed. Surgical exposure revealed compression of both CA and SMA by the MAL. The total distance of caudal arterial displacement was >3 cm. Both the CA and SMA were chronically stenotic/occluded secondary to this compression. After division of the MAL, a retrograde aortoceliac and aortomesenteric bypass was performed for mesenteric revascularization. The patient recovered uneventfully and was discharged home on the third day after surgery tolerating a full diet. MALS is a pathologic entity that can affect more than the CA. This case demonstrates multivessel, mesenteric arterial insufficiency secondary to MALS sufficient to promote IMA collateralization of the SMA circulation. In young patients with CMI, multivessel MALS must be considered. In addition to MAL release, arterial revascularization may be necessary owing to stenoses from chronic compression.

Mesenteric ischemia diseases: analysis of clinical characteristics and prognosis in 26 cases

Mesenteric ischemia diseases: analysis of clinical characteristics and prognosis in 26 cases

Reinterventions for stent restenosis in patients treated for atherosclerotic mesenteric artery disease

Mesenteric artery angioplasty and stenting (MAS) has been plagued by high restenosis and reintervention rates. The purpose of this study was to review the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR). The clinical data of 157 patients treated for chronic mesenteric ischemia with MAS of 170 vessels was entered into a prospective database (1998-2010). Fifty-seven patients (36%) developed MAISR after a mean follow-up of 29 months, defined by duplex ultrasound peak systolic velocity >330 cm/s and angiographic stenosis >60%. We reviewed the clinical data, radiologic studies, and outcomes of patients who underwent reintervention for restenosis. End points were mortality and morbidity, patient survival, symptom recurrence, reintervention, and patency rates. There were 30 patients (25 female and five male; mean age, 69 ± 14 years) treated with reintervention for MAISR. Twenty-four patients presented with recurrent symptoms (21 chronic, three acute), and six had asymptomatic preocclusive lesions. Twenty-six patients (87%) underwent redo endovascular revascularization (rER) with stent placement in 17 (13 bare metal and four covered) or percutaneous transluminal angioplasty (PTA) in nine. The other four patients (13%) had open bypass, one for acute ischemia. There was one death (3%) in a patient treated with redo stenting for acute mesenteric ischemia. Seven patients (27%) treated by rER developed complications, including access site problems in four patients, and distal embolization with bowel ischemia, congestive heart failure and stent thrombosis in one each. Symptom improvement was noted in 22 of the 24 symptomatic patients (92%). After a mean follow-up of 29 ± 12 months, 15 patients (50%) developed a second restenosis, and seven (23%) required other reintervention. Rates of symptom recurrence, restenosis, and reinterventions were 0/4, 0/4, and 0/4 for covered stents, 2/9, 3/9, and 2/9 for PTA, 5/13, 8/13, and 5/13 for bare metal stents, and 1/4, 4/4, and 0/4 for open bypass. For all patients, freedom from recurrent symptoms, restenosis, and reinterventions were 70% ± 10%, 60% ± 10% and 50% ±10% at 2 years. For patients treated by rER, secondary patency rates were 72 ± 12 at the same interval. Nearly 40% of patients developed mesenteric artery in-stent restenosis, of which half required reintervention because of symptom recurrence or progression to an asymptomatic preocclusive lesion. Mesenteric reinterventions were associated with low mortality (3%), high complication rate (27%), and excellent symptom improvement (92%).

Superior Mesenteric Artery Stent Fracture Leading to Recurrent Mesenteric Ischemia

We report 2 cases of patients with recurrent symptoms of mesenteric ischemic disease after percutaneous transluminal angioplasty (PTA) and stenting due to superior mesenteric artery stent fracture. Both patients were treated by redo PTA and stenting successfully. Stent fractures, their complications, and management are discussed.

Laparoscopy-assisted resection for Mesenteric Castleman’s disease: Report of a case

A 65-year-old female patient was diagnosed with breast cancer in 1995. An abdominal mass was detected by computed tomography and the patient was preoperatively diagnosed with a gastrointestinal stromal tumor. Laparoscopy-assisted surgical resection revealed a mesenteric Castleman's tumor of the hyaline vascular type. Mesenteric Castleman's disease is rare, and there have been only 42 cases reported in the English literature. We herein discuss the clinical findings of these cases.

Small bowel MRI in adult patients: not just Crohn’s disease—a tutorial

ObjectivesTo provide an overview of less well-known small bowel and mesenteric diseases found at small bowel magnetic resonance (MR) enterography/enteroclysis and to review the imaging findings. MR enterography and enteroclysis are important techniques for evaluation of small bowel diseases. In most centres these techniques are primarily used in Crohn’s disease, and most radiologists are familiar with these MRI findings. However, the knowledge of findings in other diseases is often sparse, including diseases that may cause similar clinical symptoms to those of Crohn’s disease.MethodsWe present a spectrum of less common and less well-known bowel and mesenteric diseases (e.g. internal hernia, intussusception, neuroendocrine tumour) from our small bowel MR database of over 2,000 cases.ResultsThese diseases can be found in patients referred for bowel obstruction, abdominal pain or rectal blood loss. Further, in patients with (or suspected to have) Crohn’s disease, some of these diseases (e.g. neuroendocrine tumour, familial Mediterranean fever) may mislead radiologists to erroneously diagnose active Crohn’s disease.ConclusionRadiologists should be familiar with diseases affecting the small bowel other than Crohn’s disease, including diseases that may mimic Crohn’s disease.

Differences in anatomy and outcomes in patients treated with open mesenteric revascularization before and after the endovascular era

To compare the clinical characteristics, anatomy, and outcomes of patients treated with open mesenteric revascularization (OR) for chronic mesenteric ischemia (CMI) before and after the preferential use of endovascular revascularization (ER). We reviewed a prospective database of 257 patients treated for CMI with OR or ER from 1998 to 2009. Treatment trends were analyzed to identify changes in practice paradigm. Prior to 2002, OR was used in 58 of 81 patients (72%). Since 2002, ER surpassed OR as the most common treatment option; OR was indicated in 58 of 176 patients (33%) who either failed ER or had unfavorable lesions for stent placement. We analyzed differences in clinical data, anatomical characteristics, and outcomes in 116 patients treated with OR before (Pre-Endo, n = 58) and after 2002 (Post-Endo, n = 58). Anatomical characteristics were determined by a blinded investigator using conventional angiography, magnetic resonance angiography, and computed tomography angiography with centerline of flow measurements. Both groups had similar demographics, risk factors, and clinical presentation, with the exception of higher (P < .05) rates of hypertension, hyperlipidemia, cardiac interventions, dysrhythmias, and higher comorbidity scores in the Post-Endo group. This group also had more extensive mesenteric artery disease, including higher incidence of three-vessel involvement (76% vs 57%; P = .048) and superior mesenteric artery (SMA) occlusion (67% vs 41%;P = .005). There were no differences (P > .05) in the number of vessels revascularized (1.8 ± 0.4 vs 1.7 ± 0.5) and in graft configuration (antegrade, 91% vs 78%; retrograde, 9% vs 22%; two-vessel, 69% vs 81%) in the Pre- and Post-Endo groups, respectively. There were no differences in operative mortality (1.7% vs 3.4%), morbidity (43% vs 53%), length of stay (12 ± 1 vs 12 ± 1 days), and immediate symptom improvement (88% vs 86%) in the Pre- and Post-Endo groups, respectively. Mean follow-up was 57 ± 6 months for patients treated before 2002 and 29 ± 6 months for those treated after 2002 (P = .0001). At 5 years, primary and secondary patency rates and recurrence-free survival were 82%, 86%, and 84% in the Pre-Endo and 81%, 82%, and 76% in the Post-Endo groups (P > .05). OR has been used in approximately one-third of patients treated for CMI since 2002. Despite more comorbidities and more extensive mesenteric artery disease in patients now treated with OR, outcomes have not changed compared with those operated prior to the preferential use of mesenteric stents before 2002.

A case of atherosclerotic inferior mesenteric artery aneurysm secondary to high flow state

Inferior mesenteric artery aneurysms are very rare and they are among the rarest of visceral artery aneurysms. Sometimes, the distribution of the blood flow due to chronic atherosclerotic occlusion of some arteries can establish an increased flow into a particular supplying district (high flow state). A high flow state in a stenotic inferior mesenteric artery in compensation for a mesenteric occlusive disease can produce a rare form of aneurysm. We report the case of an atherosclerotic inferior mesenteric aneurysm secondary to high flow state (association with occlusion of the celiac trunk and severe stenosis of the superior mesenteric artery), treated by open surgical approach.

Outcomes of Mesenteric Reinterventions for In-Stent Restenosis in Patients Treated for Atherosclerotic Mesenteric Artery Disease

Objective: Mesenteric artery stents (MAS) for chronic mesenteric ischemia (CMI) have been plagued by high restenosis and reinterventions rates. This study reviewed the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR) with open surgical (OR) or redo endovascular mesenteric revascularization (ER). Methods: The clinical data of 157 patients (190 MAS) treated for CMI were entered into a prospective database (1998-2010). Fifty-six patients (37%) developed MAISRs, defined by duplex ultrasound peak systolic velocity >350 cm/s or angiographic stenosis >60%. We reviewed the clinical data and outcomes of patients undergoing reinterventions for MAISR. End points were procedure-related mortality and morbidity, and late patient survival, symptom recurrence, reintervention, and patency rates. Results: There were 30 patients (19%) treated for MAISR, including 25 women and 5 men, with a mean age of 69 ± 14 years. Twenty-four patients presented with recurrent symptoms (27 chronic and 3 acute), and 6 had asymptomatic preocclusive lesions. Twenty-six patients (87%) had endovascular reintervention, including stent placement in 19 (15 uncovered and 4 covered) or percutaneous transluminal angioplasty (PTA) in 7. Four patients (13%) underwent OR, including one with acute ischemia. There was one death (3%) in a patient with acute ischemia treated with redo stenting. Seven patients (27%), all treated by ER, developed complications, including access site problems in four, and distal embolization with bowel ischemia, congestive heart failure or SMA reocclusion in one each. Symptom improvement was noted in 23 of the 24 symptomatic patients (96%). After a mean follow up of 29 ± 12 months, 11 patients developed a second restenosis, and 7 required treatment for recurrent symptoms. Rates of symptom recurrence, restenosis, and reinterventions were 0/4, 0/4, and 0/4 for covered stents, 2/7, 3/7, and 2/7 for PTA, 5/14, 8/14, and 5/14 for uncovered stents, and 1/4, 4/4, and 0/4 for OR. For all patients, freedom from recurrent symptoms, restenosis and reinterventions were 70% ± 10%, 50% ± 11% and 60% ± 11% at 2 years. For patients treated with ER, secondary patency rates were 73 ± 11 at the same interval. Conclusion: Nearly 40% of patients developed mesenteric in-stent restenosis, of which half required reintervention because of symptom recurrence or a preocclusive lesion. Mesenteric reinterventions were associated with low mortality (3%), a high complication rate (27%), and excellent symptom improvement (96%).

Laparoscopic surgery for mesenteric Castleman's disease

We report herein a case of mesenteric Castleman's disease which was confirmed on pathology. A 60-year-old man was admitted to our hospital complaining of abdominal pain. On the physical examination, there was no palpable mass. Computed tomography findings and magnetic resonance imaging revealed a well circumscribed, lobulated round mass on the right side of the superior mesenteric vein. Laparoscopic surgery for the mesenteric tumor was carried out to obtain a definite diagnosis and treatment. In the operative field, the mass was located on the ascending colic mesentery and measured about 3 cm in size. It was solid and surrounded by a thin fibrous capsule. The histological diagnosis of the mesenteric tumor was hyaline vascular type Castleman's disease. The postoperative course of the patient was uneventful, and he was discharged on the 10th postoperative day.

Focused Update: ACC/AHA Guidelines on Peripheral Arterial Disease

Sponsoring Organizations: American College of Cardiology, American Heart Association, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society for Vascular Medicine, Society for Vascular Surgery Background and Purpose: Changes to recommendations for the management of lower-extremity arterial and abdominal aortic disease reflect clinical-study evidence published since completion of the 2005 guidelines. The 2005 recommendations regarding renal and mesenteric arterial disease remain unchanged in the absence of new pivotal studies of disease in these segments. Key Points: 1. Because peripheral arterial disease (PAD) is often underdiagnosed and undertreated before limb ischemic symptoms become severe, an ankle–brachial index (ABI) should now be obtained in all nondiabetic patients with suspected lower-extremity …

Endovascular treatment for chronic atherosclerotic occlusive mesenteric disease: Is stenting superior to balloon angioplasty?

Endovascular treatment is an increasingly used therapeutic option in patients with chronic atherosclerotic occlusive mesenteric disease. Purpose of this study was evaluation of patency and mortality in patients treated with visceral artery percutaneous transluminal angioplasty (PTA) or stenting including follow-up. A retrospective review of 17 consecutive patients (4 women, 13 men) with endovascular treatment for symptomatic chronic mesenteric ischemia from 1998 to 2004 was performed. Mean follow-up period was 42 months. Patient demographics, interventional details, primary and/or secondary patency and mortality were recorded. Cumulative mortality and patency rates were determined using Kaplan-Meier life table analysis. Twenty-six interventions (PTA alone n=13, PTA and stenting n=13) were performed in 17 patients. Interventions were performed in the superior mesenteric artery (n=13) and celiac artery (n=13). The re-intervention rate was 30% (6/26). Re-interventions were performed for the superior mesenteric artery (n=4) and celiac artery (n=2). Cumulative overall 1-year results were primary patency rate 81%, secondary patency rate 94%, and survival rate 82%. Cumulative 10-year results were primary patency rate 73%, secondary patency rate 94%, and survival rate 65%. The 10-year secondary patency rate was 100% in patients post initial stenting and 86% in patients post initial PTA. Long-term follow-up post endovascular treatment for chronic mesenteric ischemia demonstrated a considerable overall secondary patency rate of 94%. However, the long-term secondary patency rate was higher in patients post initial stenting compared to PTA alone.

Role of Imaging in the Preoperative Staging of Small Bowel Neuroendocrine Tumors

Imaging studies are important in the preoperative staging of patients with small bowel neuroendocrine tumors (NET) and when selecting patients for cytoreduction procedures for metastatic disease. The purpose of this study was to assess the accuracy of preoperative imaging compared with operative findings in the staging of small bowel NET. Sixty-four patients with small bowel NET undergoing laparotomy and who had preoperative imaging with combinations of CT, MR, and radionuclide scintigraphy were reviewed. Results of imaging studies were compared with operative findings to assess the ability of these investigations to detect mesenteric, peritoneal, and hepatic metastases. Mesenteric nodal metastases were seen on imaging in 47 (73%) patients and were present at laparotomy in 56 (88%) patients. Peritoneal metastases were seen on preoperative imaging in 4 (6%) patients and found at laparotomy in 16 (25%) patients. Hepatic metastases were seen on imaging in 42 patients (66%) and found at laparotomy in 49 (77%). Sensitivity and specificity for detection of hepatic metastases were 77% and 100% for CT, 82% and 100% for MR, 63% and 100% for (123)I-meta-iodobenzylguanadine scintigraphy, and 63% and 100% for (111)In-octreotide. Imaging studies failed to detect hepatic metastases in 7 patients and underestimated the extent of hepatic metastatic disease in 17 patients. Imaging of small bowel NET, even with combinations of CT, MR, and radionuclide studies, underestimates the extent of peritoneal, mesenteric, and hepatic metastatic disease. Accurate staging of small bowel NET might be best performed at the time of laparotomy.

Mesenteric Castleman's Disease: Case Report and Literature Review

A 41-year-old man was discovered to have a pelvic mass during investigation for hypertension 2 years ago. Otherwise, he was asymptomatic, and abdominal magnetic resonance imaging revealed a highly vascular solid mass superior to the urinary bladder. A 131I-meta-iodobenzylguanidine whole body scan was reported as normal, which ruled out the possibility of extra-adrenal pheochromocytoma. No definitive preoperative diagnosis could be established. Surgical resection of the tumour revealed mesenteric Castleman's disease, hyaline vascular type. Such a diagnosis should be considered for any abdominal vascular mass.

Use of nondebulkability score to predict residual disease and surgical morbidity in ovarian cancer.

e15508 Background: Neoadjuvant chemotherapy, compared to primary surgery, may be associated with less morbidity and comparable survival in a subset of ovarian cancer patients. There is no paradigm for selecting primary surgery versus neoadjuvant chemotherapy. The optimal duration of chemotherapy prior to interval surgery is also unknown. The purpose of this study is to develop a non-debulkability score (NDS). Methods: We identified 102 consecutive institutional cases of women with stage IIIC-IV ovarian cancer undergoing surgical management during the past 5 years. CT scans were reviewed for pleural effusions, ascites, studding, diaphragmatic, mesenteric, peri-splenic (PS), peri-hepatic and peri-colonic disease and retroperitoneal lymphadenopathy. Multivariate assessment of preoperative factors was carried out using backward stepwise regression (sig = p < 0.05). Results: 77 patients underwent initial surgery and 25 patients were treated with chemotherapy followed by surgery. 71 of 102 (70%) patients were optimally cytoreduced (residual disease \h = 1 cm). 27% of patients had microscopic residual disease (RD), 44% had between 0-1 cm, 5% had between 1-2 cm and 24% of patients had > 2 cm of RD. High CA-125 level (p \h 0.03), low albumin (p \h 0.03), high platelets (p \h 0.05) and para-aortic lymphadenopathy (PaL) (p \h 0.005) were predictive of RD. Low albumin (p \h 0.03), PS (p \h 0.001) and PaL (p \h 0.04) were predictive of a major surgical complication (COMP = organ injury, reoperation, death). NDS (0-70) was determined by adding 10 points each for CA-125 level > 500, platelets > 500K, PS and 20 points each for albumin \h 2.7, PaL. Mean NDS of patients who had successful surgery (optimal cytoreduction and no COMP) was significantly lower compared to patients who had unsuccessful surgery (suboptimal cytoreduction or COMP) (11 ± 2 versus 37 ± 3; p \h 0.0001). The sensitivity, specificity, PPV and NPV of NDS were 85%, 88%, 93% and 73%; respectively. Conclusions: CA-125, albumin, platelets, PS and PaL predicted successful surgery. NDS may be useful in selecting initial treatment in advanced ovarian cancer patients. For patients receiving neoadjuvant chemotherapy, NDS might further help guide optimal timing of interval surgery. No significant financial relationships to disclose.

Chronic Mesenteric Ischemia: How to Select Patients for Invasive Treatment

Chronic mesenteric ischemia (CMI) remains a well-described disease process that is difficult to diagnose. Since its initial description more than a century ago, a myriad of diagnostic and treatment modalities have been applied to ameliorate the classic symptoms of postprandial abdominal pain and weight loss. It is estimated that mesenteric occlusive disease affects approximately 1% to 18% of the population, with a majority of these patients manifesting no symptoms of CMI. While associated with a small prevalence, the potential economic impact of this disease process, with the increasing age of the population and the catastrophic outcomes associated with no treatment, is significant. The primary etiology of CMI is atherosclerotic occlusive disease involving the ostia of the mesenteric arteries. Several studies have investigated the pathophysiology of the postprandial abdominal pain associated with ischemia focusing on transport mechanisms, claudication of the intestinal musculature, and ischemia of the visceral nerves. The process of diagnosing CMI involves assimilation of the presentation, typical history and physical examination findings, and results of imaging modalities. At the end of this diagnostic process, the decision to offer a patient surgical intervention is primarily based on symptomatology and results of duplex and other imaging modalities. There are specific criteria for which to offer symptomatic patients interventions. Patients who are asymptomatic do not need to undergo revascularization, which may disrupt collateral arterial circulation to the mesentery. They should be followed conservatively.

Reduction of Superior Mesenteric Hemodynamic Responsiveness to [Sar^1, Thr^8]-Angiotensin Ⅱ and Bradykinin, But Not Sodium Nitroprusside, in the Presence of Homocysteine Infusion

Hyperhomocysteinemia (HHcy) has been shown to be an independent risk factor for cardiovascular diseases, superior mesenteric thrombosis and inflammatory bowel disease. Superior mesenteric artery (SMA) supplies the intestine and reduced SMA blood flow results in intestinal ischemia. Although in vitro studies have shown that endothelium-dependent vasorelaxation of SMA is reduced in the presence of homocysteine incubation, it is not confirmed with in vivo studies. In this work, we evaluated responsiveness of SMA to endothelium-dependent or -independent vasodilators and a vasoconstrictor in the absence and presence of acute HHcy in vivo to clarify effect of HHcy on superior mesenteric vascular function. Sodium nitroprusside (SNP), bradykinin (BK), and [Sar1,Thr8]angiotensin II ([Sar1,Thr8]-ANG II) were intravenously administrated in sequence in male Sprague-Dawley rats with or without D,L-homocysteine infusion (6 mg/kg/min) through femoral vein. Agonists-induced changes in carotid artery blood pressure, superior mesenteric blood flow and vascular resistance were measured in the present study. We found that acute HHcy infusion had little effects on SNP-induced hemodynamic changes; however, BK-induced changes in blood pressure, blood flow and vascular resistance were significantly reduced in the presence of HHcy infusion. Additionally, HHcy also markedly decreased [Sar1,Thr8]-ANG II-induced superior mesenteric hemodynamic changes. These results demonstrated that responsiveness of SMA to vasoconstrictor, endothelium-dependent, but not endothelium-independent vasodilator, was inhibited in the presence of Hcy infusion. This HHcy-associated vascular hyporesponsiveness to vasoconstrictors and endothelium-dependent vasodilators may partially contribute to circulatory dysfunctions.

Assessment of activity of Crohn's disease by Doppler sonography of superior mesenteric artery flow

BackgroundEvaluation of activity of Crohn's disease is based on CDAI. Several other tools have been studied to assess disease activity with more accuracy. AimsTo assess the correlation between Doppler parameters of superior mesenteric artery and disease activity and to assess the accuracy of these parameters in discriminating between active and quiescent Crohn's disease. Material and methodsWe perform a prospective study including non-operated and non-complicated Crohn's disease patients involving terminal ileum and/or right colon and sex and age-matched controls. Doppler sonography of superior mesenteric artery was performed in all subjects. ResultsWe studied 41 patients and 15 controls. There was no statistical difference between patients and controls according to the studied US parameters. The difference in resistance index between the three groups using analysis of variance is not significant (p=0.064). Resistance index was significantly lower in patients with active disease compared to inactive disease patients (0.82+/−0.04 vs 0.85+/−0.03; p=0.01). Pulsatility index was also lower in patients with active disease compared to inactive disease patients (1.37+/−0.21 vs 1.53+/−0.15; p=0.01). A value of resistance index less than 0.79 predicted active disease with a sensitivity of 35.3% and specificity of 95.7%. A value of pulsatility index less than 1.56 predicted active disease with a sensitivity of 94.1% and specificity of 43.5%. In case of resistance index less than 0.79 and pulsatility index less than 1.56 in the same patient, the probability of active disease was 86%. However, in case of resistance index over than 0.79 and pulsatility index over than 1.56, this probability was only 9%. In Crohn's disease patients, correlation study showed that resistance index value was significantly correlated with CDAI (r=−0.46; p=0.003). Pulsatility index value was also correlated with CDAI (r=−0.39; p=0.01). ConclusionDoppler sonographic parameters of superior mesenteric artery are significantly correlated with disease activity in non-operated and non-complicated Crohn's disease.

Letter to the Editor

September 2007 Dear Editor, PRIMARY ILEAL MESENTERIC HYDATIDOSIS: A RARE CAUSE OF COLICKY ABOMINAL PAIN IN CHILDHOOD A 3-year old boy from a rural village in western India presented with intermittent pain in his abdomen for a duration of 15 days, associated with weight loss of around 6 kg over 3 months, which his mother put down to loss of appetite. His family ran a cattle farm and had intimate contact with goat and sheep. There was no history of hydatid disease in other members of the family who all lived under one roof. On examination, he had mild tenderness in the right hypochondrium and a vague, irregular, mobile, palpable mass, but no abdominal distension or visible peristalsis. Full blood count, alanine transaminase, alkaline phosphate, aspartate transaminase, gamma glutamyl transpeptidase, bilirubin and blood glucose were normal. An abdominal ultrasound showed multiple cystic areas in the central abdomen, with cysts measuring 2 mm to 8 cm with multiple loculi. The liver, spleen and kidneys were normal (Fig. 1). The provisional diagnosis was mesenteric hydatid disease and the patient underwent laparotomy and resection of the affected small bowel segment. The involved ileum and mesenteric mass including all hydatid cysts were excised. The liver and other organs were free of the disease. The gross specimen, a 25 × 25 × 15 cm mesenteric cystic mass, consisted of the terminal portion of jejunum and proximal portion of ileum (Fig. 2). Histopathology showed multiple daughter cysts within larger cysts that varied in diameter from 0.4 to 8 cm. He was discharged, taking long-term cyclic treatment with albendazole (10 mg/kg daily for 8 months as per World Health Organisation recommendations). Consecutive ultrasounds over 5 years showed no recurrence. Ultrasound showing multi-cystic areas in abdomen. Intra-operative picture showing small bowel mesentery mass with multiple multi-cystic masses and daughter cysts of varying sizes. Hydatid disease in humans is caused by Echinococcus granulosus (dog tapeworm). The dog is the definitive host. Ova shed in dog faeces infect the intermediate host (e.g. cattle, sheep), making it endemic in lamb/sheep rearing countries. Human infection occurs after the ingestion of ova, which penetrate the intestinal wall, passing via the portal vein into the liver, lungs and other tissues. A hydatid cyst can develop anywhere in the body, most commonly in the liver, although <25% occur in the lungs.1,2 Immigration, travel and migration make this disease globally important. Infections affecting bone are rare but they have been reported in pathology text and articles. The patient can present with pain in the abdomen, hepatomegaly, loss of weight, failure to thrive and complications due to the rupture of a cyst into the peritoneal cavity, anaphylactic shock, eosinophilia, urticaria, implantation into other organs and viscera, jaundice and cholangitis.3 This boy's clinical presentation at such a young age was atypical. We present this case to illustrate the importance of ultrasound scan in diagnosis.

La mesentérite sclérosante est-elle une maladie dysimmunitaire à IgG4 ?

Mesenteric panniculitis (MP), sclerotic mesenteritis (SM) and mesenteric lipodystrophy (ML) are the three histopathological forms of a rare inflammatory mesenteric disease. The pathogenesis is unknown until now. Hypothesis of a dysimmune disorder is advocated. Our purpose was to find histological basis to assert this hypothesis. All patients with a diagnosis of inflammatory mesenteric disease made in Beaujon hospital were selected. A histological study and a systematic immunostaining with IgG4, CD3 and CD8 antibodies were performed for each patient with paraffin block available. Dysimmune features were defined by: a plasma cells component >30 %, an eosinophilic polynuclears component >10 %, a rate TCD8/CD3 >30 % and IgG4+ plasma cells >30/high power field (x400). Cases were classified in 3 forms on the basis of the predominant component: MP (lymphoid/plasma cell infiltrate), SM (fibrosis), ML (fat necrosis). Thirteen patients (7 men, 6 women) were selected, with a mean age of 57 years (21-80 years); a paraffin block was available for 10 patients. The clinical and histological presentations were heterogeneous: a mesenteric mass was the most frequent mode of revelation (6/13 patients) and all histological forms were present (3 MP, 5 SM and 5 ML). Nine patients had surgical biopsy, 2 had a trephine biopsy and 2 a resection. Standard histological analysis showed numerous eosinophils (> or =10 %) and plasma cells (>30 %) in respectively 3 (23 %) and 6 (46 %) of the 13 cases. The immunohistochemistry (performed in 10 patients) showed numerous TCD8+ in 80 % of the cases and numerous IgG4+ plasma cells in only 31 % of the cases (4 cases) (IgG4+ >30/x400). Our results demonstrate that inflammatory mesenteric diseases are heterogeneous: high components of plasma cells, eosinophils and TCD8+ lymphocytes were found respectively in 46, 23 and 80 % of cases; eosinophils were observed exclusively in sclerotic forms. Only 31 % of cases encompass numerous IgG4+ plasma cells, suggesting a pathogenesis different than hyper-IgG4 diseases.