Acute Nonspecific Mesenteric Lymphadenitis: More Than "No Need for Surgery".

Acute nonspecific, or primary, mesenteric lymphadenitis is a self-limiting inflammatory condition affecting the mesenteric lymph nodes, whose presentation mimics appendicitis or intussusception. It typically occurs in children, adolescents, and young adults. White blood count and C-reactive protein are of limited usefulness in distinguishing between patients with and without mesenteric lymphadenitis. Ultrasonography, the mainstay of diagnosis, discloses 3 or more mesenteric lymph nodes with a short-axis diameter of 8 mm or more without any identifiable underlying inflammatory process. Once the diagnosis is established, supportive care including hydration and pain medication is advised. Furthermore, it is crucial to reassure patients and families by explaining the condition and stating that affected patients recover completely without residuals within 2-4 weeks.

[An uncommon case of purulent mesenteric lymphadenitis]. / Neobvyklý prípad mezenteriální abscedující lymfadenitidy.

The authors present a case of a middle-aged female with large isolated mesenteric lymphadenitis. Abdominal ultrasonography undertaken as a preventive assessment revealed a solid tumour mass in the left mesogastrium, sized 70x55x55 mm. A solid abdominal tumour such as a GIST or sarcoma was considered and the patient underwent elective laparoscopic surgery. The tumour was completely removed. Histopathological examination confirmed an unexpected result of nonspecific purulent mesenteric lymphadenitis. The authors discuss potential causes of mesenteric lymphadenitis.Key words: abdominal tumour mesenteric lymphadenopathy purulent lymphadenitis - solitary lymphadenopathy.

Role of serum cytokines in acute appendicitis and acute mesenteric lymphadenitis among children.

BACKGROUND AND OBJECTIVE: The diagnostic role of serum cytokines depends on the etiology and pathogenesis of acute appendicitis (AA) and acute mesenteric lymphadenitis (AML). The aim of this study was to evaluate differences in cytokine levels between AA and AML. MATERIALS AND METHODS: Data of 7- to 18-year-old children were collected prospectively from October 2010 to October 2013. There were 31 patients with AA (AA group), 26 with AML (AML group), and 17 with elective non-inflammatory surgical disease (control group). Serum levels of IL-10, IL-12(p70), IL-1ß, IL-4, IL-6, IL-8, IL-17, MCP-1, EGF, TNF-α and white blood count (WBC) were measured three times consecutively in each group. RESULTS: The level of IL-6 and IL-10 was significantly higher in the AA group than the AML group at the first measurement (8pg/mL vs. 3.2pg/mL, P=0.000; 6.1pg/mL vs. 3.2pg/mL, P=0.005, respectively). There was a significant difference observed in time dynamics of concentration of IL-6 and MCP-1 for AA and AML. The area under the curve (AUC) was 0.77 (95% CI 0.64-0.89; P=0.001) for IL-6 with a cut-off value of 4.3pg/mL (67.7% sensitivity and 76.9% specificity) for AA 1h before surgery. The AUC for WBC was 0.72 (95% CI 0.58.4-0.85; P=0.005) with a cut-off value of 10.7×103/µL (sensitivity 71.0% and specificity 46.2%). CONCLUSIONS: Serum IL-6 with a cut-off value of 4.3pg/mL and WBC with a cut-off value of 10.7×103/µL assessed together will yield more sensitivity for AA.

ROLE OF DIAGNOSTIC LAPAROSCOPY IN EVALUATION AND TREATMENT OF CHRONIC ABDOMINAL PAIN IN CHILDREN.

BACKGROUND: Chronic abdominal Pain in children is a very common cause of hospital admission. Many of them are discharged without a diagnosis even after battery of investigations. Laparoscopy plays a significant role in diagnosis and management of many causes of acute and chronic abdominal pain. The purpose of this study was to determine the efficacy of laparoscopy as an efficient diagnostic and management tool in children with chronic abdominal pain. METHODS: A descriptive, prospective case series was collected in the department of Paediatric surgery Mayo's Hospital Lahore, over the period of 5 years between Jan 2007-Dec 2013. The data of consecutive 50 patients, who were admitted in the department with the diagnosis of chronic abdominal pain, was recorded. All patients who had 2-3 admissions in hospital for last 2 months and failed to establish a definitive diagnosis after clinical examination and base line investigations underwent laparoscopy. The details of associated symptoms, finding of laparoscopy, laparoscopic procedures done, definitive diagnosis, histopathology, complications and relief of symptoms were collected and analysed and results were evaluated using SPSS-17. RESULTS: Out of 50 patients studies, 27/50 (54%) were male, 23/50 (46%) were female. Age ranged from 2-12 years, with the mean age of 7.24 year. Tuberculosis abdomen, adhesions, mesenteric lymphadenitis, appendicitis and cholecystitis were the final diagnosis. Five abdomens were found normal on laparoscopy. Complete pain relief was achieved in 30/50 (60%), reduced intensity of pain was gained in 12/50 (24%) cases while 16% (8/50) still complained of pain. CONCLUSIONS: Laparoscopy is an efficient diagnostic and treatment tool in children with chronic unexplained abdominal pain. It avoids serial examinations; prolong admission, battery of investigations and unnecessary surgeries.

Is mesenteric lymphadenitis a cause of ovarian reserve reduction? - Case Report.

Mesenteric lymphadenitis is a clinical condition that affects mostly children and teenagers. Its symptoms include fever, severe abdominal pain, nausea, and, in some cases, diarrhea, constipation, and acute abdomen. This paper describes the case of a 16-year-old patient with mesenteric lymphadenitis submitted to an exploratory laparoscopy for suppurative lymph nodes that evolved to a drastic reduction of ovarian reserve. Because of the patients age, she was offered cryopreservation of her ovarian tissue.

[MICROBIAL LANDSCAPE OF BILE IN PATIENTS WITH AN ACUTE PURULENT CHOLANGITIS].

Bacteriological analysis was conducted in 136 patients with an acute purulent cholangitis (APCH). The APCH causes were: choledocholithiasis--in 40 (29.9%) patients, coexistence of a common biliary duct stricture and choledocholithiasis--in 39 (28.7%), compression of external biliary ducts by the oedematous pancreatic head in secondary pancreatitis--in 15 (11%), pericholedocheal lymphadenitis--in 3 (2.2%).

Kikuchi- Fujimoto disease of mesenteric lymph nodes mimicking acute appendicitis.

Kikuchi-Fujimoto disease, or histiocytic necrotising lymphadenopathy of unknown aetiology, is a rare, benign and self-limiting cause of lymphadenopathy often involving the cervical nodes, and rarely presenting with mesenteric lymphadenopathy. We present a 26-year-old Caucasian male, who presented with right iliac fossa pain and low grade pyrexia, mimicking acute appendicitis. He underwent a laparatomy and an extended right hemi-colectomy for a caecal mass. Histology of the specimen showed lymph nodes with extensive areas of necrosis, with abnormal architecture suggesting Kikuchi-Fujimoto lymphadenopathy. This was further confirmed by immunohistochemistry. In this context maintenance of a high index of suspicion of this condition can avoid major surgical interventions. We describe the management of our case of Kikuchi-Fujimoto's disease involving the mesenteric nodes and provide an up to date review of the pertinent literature on this subject.

Unexpected findings on laparoscopy for suspected acute appendicitis: a pro for laparoscopic appendectomy as the standard procedure for acute appendicitis.

PURPOSE: Evaluation of the feasibility, cost-effectiveness, time of surgery, morbidities, and other/additional findings during laparoscopy for suspected appendicitis. METHODS: Prospective evaluation of 148 laparoscopies for suspected acute appendicitis. RESULTS: Laparoscopic appendectomy was safe and cost-effective. No appendiceal stump leaks or wound infections occurred. Of the patients, 4.7% developed intra-abdominal abscesses. Mean time of all procedures was 47 min: 42 min for simple appendectomies (n = 126), 67 min for perforated appendicitis (n = 15), and 75 min for converted procedures (n = 7). Twenty-one of 148 (14.2%) patients had unexpected findings instead of appendicitis: inflamed epiploic appendices (three times), inflammatory disorders of intestine (five times), intestinal adhesions (two times), ovarian cysts (six times: one time with mesenteric lymphadenitis, one time ruptured), tubo-ovarian abscess (one time), tubal necrosis (one time), adnexitis with mesenteric lymphadenitis (one time), and acute cholecystitis (one time). These diagnoses might have been missed during conventional open appendectomy and were, if necessary, treated during laparoscopy. CONCLUSIONS: Laparoscopic appendectomy should be recommended as standard procedure for acute appendicitis.

Congenital absence of the cecal appendix. Case report.

BACKGROUND: Agenesis of the vermiform appendix is very rare and was first described by Morgagni in 1718. The estimated incidence is 1/100,000 laparotomies performed for suspected appendicitis. This case is reported with the aim of attracting the attention of surgeons who may be in a similar situation during laparotomy. CLINICAL CASE: A 48-year-old male was admitted through the emergency room with the complaint of vague abdominal pain most marked in the epigastrium and mesogastrium which, 4 h after it began, was located in the right iliac fossa and was accompanied by hyporexia, nausea, vomiting and fever. During physical examination, the patient was febrile, tachycardic, and tachypneic, with decreased peristalsis, abdomen painful to palpation and percussion in the right iliac fossa. There were positive appendicular signs. Blood panel showed leukocytosis (14,000), neutrophilia (89.60%) and lymphopenia (5.33%). X-rays of the abdomen showed no abnormalities. We made a presumptive diagnosis of acute appendicitis and the patient underwent celioscopy where surgical findings were reported as type IV Collins appendiceal agenesis and concomitant mesenteric adenitis. CONCLUSIONS: Several criteria must be determined before the surgeon can conclude that the appendix is congenitally absent. Diagnosis should not be confirmed until the ileo- and retrocecal regions have been explored.

Agenesia del apéndice cecal: informe de un caso / Congenital absence of the cecal appendix: case report

Introducción: La agenesia del apéndice cecal es muy rara y fue descrita por primera vez por Morgagni en 1718. La incidencia estimada es de uno por cada 100 mil laparotomías realizadas por sospecha de apendicitis. Se informa este caso con la finalidad de atraer la atención de los cirujanos que se encuentren en situación similar durante la laparotomía. Caso clínico: Hombre de 48 años de edad admitido en la sala de urgencias por dolor abdominal de tipo vago, más notable en epigastrio y mesogastrio, el cual cuatro horas después de iniciado se localizó en la fosa iliaca derecha, acompañado de hiporexia, náusea, vómito y fiebre. A la exploración física se encontró paciente febril, taquicárdico, taquipneico, con peristaltismo disminuido, abdomen doloroso a la palpación y a la percusión en la fosa iliaca derecha. Signos apendiculares positivos. La biometría hemática indicó leucocitosis de 14 mil, neutrofilia (89.60 %) y linfopenia (5.33 %). Las radiografías simples de abdomen no mostraron anormalidades. Se formuló diagnóstico de probable apendicitis aguda, por lo que se efectuó celioscopia, identificándose agenesia apendicular tipo IV de Collins y adenitis mesentérica concomitante. Conclusiones: Se tienen que conocer varios criterios antes de concluir que el apéndice cecal está ausente de manera congénita. El diagnóstico no debe realizarse hasta que la regiones ileocecal y retrocecal hayan sido exploradas.

BACKGROUND: Agenesis of the vermiform appendix is very rare and was first described by Morgagni in 1718. The estimated incidence is 1/100,000 laparotomies performed for suspected appendicitis. This case is reported with the aim of attracting the attention of surgeons who may be in a similar situation during laparotomy. CLINICAL CASE: A 48-year-old male was admitted through the emergency room with the complaint of vague abdominal pain most marked in the epigastrium and mesogastrium which, 4 h after it began, was located in the right iliac fossa and was accompanied by hyporexia, nausea, vomiting and fever. During physical examination, the patient was febrile, tachycardic, and tachypneic, with decreased peristalsis, abdomen painful to palpation and percussion in the right iliac fossa. There were positive appendicular signs. Blood panel showed leukocytosis (14,000), neutrophilia (89.60%) and lymphopenia (5.33%). X-rays of the abdomen showed no abnormalities. We made a presumptive diagnosis of acute appendicitis and the patient underwent celioscopy where surgical findings were reported as type IV Collins appendiceal agenesis and concomitant mesenteric adenitis. CONCLUSIONS: Several criteria must be determined before the surgeon can conclude that the appendix is congenitally absent. Diagnosis should not be confirmed until the ileo- and retrocecal regions have been explored.

[Intestinal tuberculosis of the terminal ileum causing obstructive ileus and tuberculous peritonitis and presenting numerous peritoneal small red nodules: a case report].

A 38-year-old woman suffering from lower abdominal pain was referred to our hospital. Abdominal computed tomography showed marked thickening of the terminal ileum to the cecum, localized collection of ascites, and multiple mesenteric lymphadenopathy. A barium contrast small bowel series showed solitary severe stenosis of the terminal ileum with marked swelling of the ileocecal valve, where colonoscopy could not pass through, suggesting that ileal stenosis was caused by intestinal tuberculosis. She also showed strongly positive tuberculin skin test. Laparoscopy-assisted ileocecal resection was performed for confirmation of diagnosis and removal of the stenotic intestinal lesion. Laparoscopically, numerous small red nodules scattered on the stenotic ileal serosa, peritoneum, and mesenterium. Histopathological examination revealed ileal tuberculosis causing ulcerative stricture, and mesenteric tuberculous lymphadenitis. The small red nodules were formed of hemorrhagic tuberculous nodules.

The risk of developing Crohn's disease after an appendectomy: a population-based cohort study in Sweden and Denmark.

BACKGROUND: The relationship between appendectomy and Crohn's disease is controversial. A Swedish-Danish cohort study was conducted to assess the risk of developing Crohn's disease after an appendectomy. METHODS: 709 353 appendectomy patients in Sweden (since 1964) and Denmark (since 1977) were followed for first hospitalisations for Crohn's disease to 2004. Standardised incidence ratios (SIR) served as relative risks. RESULTS: Overall, 1655 Crohn's disease cases were observed during 11.1 million person-years of follow-up. Whereas appendectomy before the age of 10 years was not associated with the risk of Crohn's disease (SIR 1.00; 95% CI 0.80-1.25), the overall SIR of developing Crohn's disease was 1.52 (95% CI 1.45-1.59), being highest in the first 6 months (SIR 8.69; 95% CI 7.68-9.84). SIR diminished rapidly thereafter, with the risk of Crohn's disease reaching background levels after 5-10 years for Crohn's disease overall, as well as for Crohn's ileitis, ileocolonic Crohn's disease, Crohn's colitis and other/unspecified Crohn's disease. A long-term increased risk of Crohn's disease up to 20 years after the appendectomy was seen only in appendectomy patients without appendicitis or mesenteric lymphadenitis. CONCLUSION: The transient increased risk of Crohn's disease after an appendectomy is probably explained by diagnostic bias.

Cirugía laparoscópica ante la sospecha clínica de apendicitis aguda. Estudio prospectivo de 500 casos consecutivos / Laparoscopic surgery and the clinical suspicion of acute appendicitis. Prospective study of 500 consecutive cases

Introducción. La apendicitis aguda es uno de los cuadros clínicos más frecuentes en la patología quirúrgica. El objetivo del presente estudio es valorar los resultados de la utilización de la exploración laparoscópica ante la sospecha clínica de apendicitis aguda. Pacientes y método. Análisis prospectivo de los resultados obtenidos en 500 exploraciones laparoscópicas consecutivas por sospecha de apendicitis aguda. Aplicación de un score de predicción de complicaciones sépticas intraabdominales. Resultados. En el 83,2 por ciento de los procedimientos, el diagnóstico de apendicitis aguda fue correcto. La causa más frecuente de error diagnóstico fue la enfermedad ginecológica. Se llegó a un diagnóstico definitivo en el 98,2 por ciento de los casos. El 93,75 por ciento de los casos de apendicitis aguda se pudieron resolver por vía laparoscópica. La aplicación de un score predictivo permitió reducir el porcentaje de complicaciones sépticas intraabdominales de un 5,5 a un 1,3 por ciento. Conclusiones. La laparoscopia permite una elevada certeza diagnóstica y una alta rentabilidad terapéutica. La aplicación de un score predictivo de complicaciones sépticas intraabdominales permite reducir drásticamente el porcentaje de presentación de abscesos intraabdominales (AU)

Acute postoperative dermatosis at the site of the electrocautery pad: sweet diagnosis of a burning issue.

Acute febrile neutrophilic dermatosis or Sweet's syndrome is a well-described acute condition with possible paraneoplastic and inflammatory associations. A case of a 49-year-old man with a prior history of Hodgkin's disease is described, who underwent a laparotomy for operative treatment of a small intestinal stricture and therapy-refractory gastroesophageal reflux. Incidentally, mild mesenteric lymphadenopathy was encountered, and a biopsy confirmed the presence of a new, unrelated low-grade follicular lymphoma. Two weeks postoperatively, the patient developed a tender erythematous plaque at the site of the Bovie electrocautery pad on the proximal thigh. Over the following week, the affected area extended in size, and became markedly edematous and infiltrated, with hemorrhagic surface studding. Multiple small plaques, some with annular arrays of pustules, were found on the opposite lower extremity, the lower back, and the arms. A skin biopsy suggested the presence of Sweet's syndrome, and corticosteroid treatment was initiated. All cutaneous manifestations disappeared within 48 h except for the presence of postinflammatory erythema. Acute neutrophilic dermatoses have not been previously described in this postoperative presentation. The differential diagnostic importance of this emergent entity and the potential for it being caused by surgical trauma are discussed.

[Diagnosis and surgical treatment of tuberculosis of mesentric lymph nodes].

OBJECTIVE: To evaluate the diagnosis, operative indication and therapeutic result of tuberculosis of mesentric lymph nodes. METHOD: Fifty-nine cases with tuberculosis of mesentric lymph nodes surgically treated at two hospitals from July 1976 to July 1997 were retrospectively analyzed. RESULT: Only 14 cases were correctly diagnosed before operation. Operative treatment for the tuberculosis of mesentric lymph nodes represented a safe, effective treatment with few complications and no operative death. CONCLUSION: Because patients with tuberculosis of mesentric lymph nodes show no characteristic manifestations, laboratory methods (e.g. polymerase chain reaction), peritoneoscopy, CT scanning and B mode ultrosound techniques should also be considered for diagnosis of the disease. The acute or chronic ileus, hemorrhage of digestive tract, intestinal perforation or fistula, intra-abdominal large tuberculous abscess and abdominal sinus caused by tuberculosis of mesentric lymph nodes should be surgically treated. The exploratory laparotomy also should be performed on the patients with abdominal mass or those whose diagnosis of neoplasm could not be ruled out. The postoperative antituberculosis chemotherapy should be continued to decrease the occurrence of complications.

Mesenteric adenitis caused by Yersinia pseudotuberculosis presenting as an abdominal mass.

Infection by Yersinia pseudotuberculosis has become of increasing pathological importance. Patients normally present with symptoms similar to those of appendicitis, due to mesenteric adenitis. We present the case of 3 patients infected by Yersinia pseudotuberculosis who in addition to fever and abdominal pain had a palpable abdominal mass, so great was the enlargement of the mesenteric nodes. In 2 patients a laparotomy was carried out, followed by biopsy of a mesenteric lymph node. The diagnosis of Yersinia infection was confirmed by bacterial culture of the biopsied material and also by serology. In the third patient, serological studies and ultrasonic imaging of the abdomen led to early diagnosis and surgery was avoided. We suggest that a diagnosis of mesenteric adenitis due to Yersinia pseudotuberculosis should now be considered in all patients presenting with an abdominal mass, and in whom there is an appropriate clinical and epidemiological history. The diagnosis should be confirmed by abdominal ultrasound (alternatively Computerised Axial Tomography or Magnetic Resonance Imaging) and serological studies. In this way, unnecessary surgery can be avoided.

[Omentitis and mesenteric lymphadenitis: is there a relationship? Apropos of 3 cases]. / Omentite ed adenomesenterite: c'è relazione? A proposito di tre osservazioni.

The authors report three cases of acute epiploitis diagnosed intraoperatively and discuss the etiopathogenetic hypotheses. They suggest a relationship between acute epiploitis and mesenteric lymphadenitis, as well as their common origin.