SUMMARY A patient with a lymphatic cyst of the descending colon is reported. He underwent segmental resection of the colon. The clinical features, pathology, radiology, and treatment of these lesions are reviewed. It is emphasized that these cysts are very rare and cannot be diagnosed radiologically, but must be included in the differential diagnosis of polypoid lesions of the colon.Lymphatic cysts (cystic lymphangiomata, lymphangiomatous, lymphangiectatic, or chylous cysts) of the abdomen are rare and can occurinthemesentery, omentum, retroperitoneum, and very occasionally in the wall of the stomach, duodenum, and the small or large intestine.The extreme rarity of the lesion and the interesting radiological appearances and differential diagnosis warrant the report of a case and a brief review of the literature. Case ReportA 65-year-old man reported a three-month history of left-sided abdominal colic and melaena. He had a normal bowel habit and there was no vomiting.On examination there was guarding and tenderness in the central abdomen and left hypochondrium. No mass could be palpated.Rectal and sigmoidoscopic examinations were negative. Double-contrast barium enema study demonstrated a large, smoothly outlined and well circumscribed polypoidal lesion with a broad base on the medial wall of the descending colon ( Figs. 1 and 2). There was diverticular disease of the sigmoid colon.At laparotomy the polypoidal mass was palpated in the upper third of the descending colon, but suddenly disappeared. (Subsequently, this was found to be due to rupture and emptying of the cyst during palpation.) A segmental resection was undertaken. The resected colon was opened and a large redundant fold of mucosa was found which was clearly all that remained of a ruptured cyst. The lesion was inflated with water and a photograph taken (Fig. 3).Received for publication 26 June 1971. PathologyThe inflated specimen was thin walled and measured 2.5 cm in diameter.Histology revealed a large unilocular submucosal cyst lined with flattened endothelium and the appearances were in keeping with those of a lymphatic cyst. There was no evidence of malignant change. DiscussionLymphatic cysts of the gut are extremely rare entities. A review of these cysts at the Mayo Clinic over a 36-year period revealed nine cases; six of these were found in the mesentery, two in the retroperitoneum, and one was of undetermined origin. No mural cysts of the alimentary tract were reported (Beahrs, Judd, and Dockerty, 1950).
SummaryAnalysis of the first year's working of a combined gastroenterology clinic in a district hospital has shown that the major benefit was improved patient management. Hospital attendances were reduced, the diagnostic process accelerated, and unnecessary radiological investigations and surgical operations avoided. There were no obvious major disadvantages. IntroductionFor many years gastroenterology has been regarded as the province of either the general physician or the surgeon, each usually working in isolation. More recently, however, gastroenterology has become accepted as a specialty which derives particular benefit from a multidisciplinary approach. Nevertheless, joint medical and surgical gastroenterological units are comparatively rare, particularly outside teaching centres, and in most hospitals the usual practice is still for gastroenterological problems to be seen initially in either the general medical or the surgical departments with subsequent cross-referral as necessary. This seemed to us an unsatisfactory arrangement, but set against a climate of financial stringency it seemed unlikely that we would obtain support for any scheme to improve the clinic organization which involved significant expenditure or structural alteration.Accordingly, we decided from the beginning of 1973 to launch a combined consultative outpatient clinic for gastroenterological problems with contributions from physician, surgeon, radiologists, and pathologist. This required nothing for its establishment other than the enthusiasm and co-operation of all parties, and the project was made easier by the fact that the physician and surgeon already had a simultaneous outpatient clinic which had the potential for a medicosurgical merger. With the support of the medical division but misgivings from the surgical department referrals to the clinic were invited for the beginning of 1973 and it soon became clear that our plan to hold the clinic fortnightly would cause an unduly long waiting list. It therefore became necessary to hold the clinic at least three times a month.
Examination under anaesthesia showed the comeae to be normal (diameter 10 mm. each eye). The ocular tension was 4 5 mm. Hg (Schi0tz) with the 5 5 gm. weight in each eye. Gonioscopy showed that only a small rim of iris tissue was present. The lenses appeared smaller than normal. Fundus examination showed a temporal crescent at both discs. There was a small hypermetropic refractive error in both eyes.There were two healthy sibs aged 18 months and 6 months. There was no family history of any form of eye anomaly.On admission the aniridia was confirmed (Fig. 1, opposite), and a large mass diagnosed clinically as Wilms's tumour (Fig. 2, opposite) was palpable on the right side of the abdomen. An intravenous pyelogram showed a large mass in the right kidney distorting the normal calyceal pattern and there was also evidence of a smaller mass in the left kidney.Pre-operative blood transfusion was necessary, a course of actinomycin-D was started, and at operation (Mr. J. Grieve) a large renal tumour was found on the right side. The inferior vena cava was blocked by local spread of the tumour. The left kidney was palpated at operation but no abnormality was found. A right nephrectomy was undertaken and the vena cava cleared by a Fogarty catheter. Microscopy confirmed that the tumour was a nephroblastoma.After the operation she was at first reasonably well but her clinical condition slowly deteriorated and despite intensive therapy she developed broncho-pneumonia and died.Post-mortem Examination (Dr. Mehroo Forbes).-This confirmed the broncho-pneumonia, and in the left kidney a mass 3 5 cm. in diameter was discovered which on microscopy was also shown to be a nephroblastoma. No metastases were found in any other organ.
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