A case of spontaneous mesenteric hematoma with diagnostic difficulty

Abstract

Background Spontaneous mesenteric hematoma (SMH) is a rare condition characterized by intraperitoneal hemorrhage of unknown etiology. SMH without worsening of general status allows conservative management; however, patients showing chronological changes on imaging require surgical intervention to rule out possible malignancy. Case presentation A 69-year-old man was referred to our hospital to evaluate an abdominal mass with no associated clinical symptoms. He had a history of chronic hepatitis C and diabetes mellitus. Six months earlier, computed tomography (CT) revealed a 75-mm tumor arising from the jejunum, suspected to be a gastrointestinal stromal tumor (GIST) of the small intestine. Following a further 6 months of observation, the patient was referred to our hospital. Abdominal contrast-enhanced CT revealed a well-defined heterogeneous round tumor with a maximum diameter of 75 mm adjacent to the upper jejunum. The tumor was accompanied by calcification at the periphery, with no evidence of augmentation over the prior 6 months. Diffuse lymphadenopathy was observed around the aorta and splenic artery. Under the diagnosis of GIST arising from small intestine, the patient underwent elective surgery. The resection revealed an elastic soft tumor at the mesentery adjacent to the upper jejunum with severe adhesion between the tumor and jejunum. The tumor origin was unclear; thus, we performed mesenteric excision and partial enterectomy without lymph node dissection. The tumor was surrounded by fibrous capsular tissue containing massive hemosiderin deposits and cholesterol crystals showing partial calcification, resulting in a diagnosis of spontaneous hematoma of the mesentery. Conclusions We report a case of SMH mimicking small intestinal GIST. It is difficult to diagnose long-established SMH because its radiological features change with time, and more case reports are needed to improve the accuracy of diagnosis.

Usefulness of 18F-fluorodeoxyglucose-positron emission tomography/computed tomography in primary cystadenocarcinoma of the mesentery: a case report

“…To our knowledge, there are no reports of the use of PET/ CT for mesenteric cystadenocarcinoma. Furthermore, only a few cases on the use of FDG-PET/CT for evaluation of retroperitoneal tumors have been reported to date, with 2 cases of benign mesenteric cysts, 1 case of a retroperitoneal cystadenocarcinoma, and 1 case of retroperitoneal cystic tumor [33][34][35][36]. The morphology of pancreatic cystic tumor and ovarian tumors is similar to that of cystadenoma and cystadenocarcinoma.…”

“…The FDG accumulation site contained more adenocarcinoma than other areas, highly suggesting that the site of FDG accumulation was not due to inflammation but as a result of adenocarcinoma. If FDG-PET/CT reveals high FDG uptake in the absence of inflammatory findings, the possibility of malignancy should be considered and appropriate treatment should be initiated [33][34][35][36]. It is difficult to distinguish benign from malignant tumors using standard radiological imaging such as CT, MRI, and US.…”

Idiopathic spontaneous lesser sac haemorrhage possibly due to endometrioma

“…7,8 Biopsy of the mass is not recommended due to the possibility of rebleeding with need for emergency surgery. 9 We postulate that the rim-enhancing cystic lesion along the omentum could have been an endometriotic deposit, as extra-pelvic endometriosis presenting with spontaneous haemorrhagic rupture has been reported in the literature. 10 Another possibility is a chronic residual haematoma which can have a similar appearance.…”

“…Conservative management with interval imaging has been described as an appropriate management option for stable patients with idiopathic spontaneous intraperitoneal haemorrhage 7,8 . Biopsy of the mass is not recommended due to the possibility of rebleeding with need for emergency surgery 9 …”

“…10 Another possibility is a chronic residual haematoma which can have a similar appearance. 9 In summary, it is important to recognize the presence of intraperitoneal blood, while avoiding mistaking it for a neoplastic mass and undertaking further unnecessary investigations or procedures. In the context of an idiopathic spontaneous intraperitoneal haematoma in a stable patient without indications for urgent surgery or angioembolization, the patient may be managed conservatively and expectantly.…”