1.Intra abdominal cysts in Children

2. Objectives What is a cyst? Types of cysts Differentials Imaging appearances 3. CYST A cyst is a closed pocket or pouch of tissue. It can be filled with air, fluid, pus, or other material http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0003724/ 4. Types Of Cysts Thin /Thick walled With / Without wall calcifications Regular/ Irregular in shape Small / Large in size With / Without internal septa ---Thin / Thick septa ----Single / Multiple 5. With / without Internal echoes ----- Fine /Thick With /Without Solid component 6. Differentials HEPATOBILIARY Choledochal Cyst Gallbladder Hydrops GASTROINTESTINAL Duplication Cyst Omental/Mesenteric Cyst URINARY TRACT Renal /parapelvic Cyst Severe Hydronephrosis/Pelviureteric junction Obstuction. Cystic Wilms Tumour (rare) Urachal Cyst 7. ADRENALS Resolving adrenal heamorrhage Cystic neuroblastoma/ Ganglioneuroma(rare) PANCREATIC Pancreatic pseudocyst PELVIC Ovarian Cyst Teratoma/Dermoid Cyst Anterior Meningocele Abscess 8. Hepatobiliary CHOLEDOCHAL CYST GALLBLADER HYDROPS 9. CHOLEDOCHAL CYST Congenital dilatations of the biliary tree Most cause symptoms in childhood and adult life. 10. TYPES (Todani s ) Type I- Cystic (51 %) or fusiform (10.6%) TypeII- Diverticulum Type IlI- Choledochocele of intraduodenal common bile duct Type IV- Extra- and intrahepatic cysts (28.5%) Type V- Intrahepatic dilatations (4.6%) 11. Complications include cholangitis, biliary calculi, pancreatitis and biliary cirrhosis. On ultrasound or CT the biliary tree dilatation or cyst can be seen. 99mTc-HIDA scinitraphy will show accumulation of tracer within the cyst. Percutanous or endoscopic cholangiography and MRCP are helpful in preoperative planning. 12. Fusiform choledochal cyst with a long common channel and associated stricture at the pancreaticobiliary junction. 13. CT of a large choledochal cyst with obstruction. 14. Ultrasound study shows a cystic mass between pancreatic head and the gallbladder. Smooth wall and homogeneous anechoic contents( tortuous cystic duct that joins the gall bladder to the cystic mass ) 15. GASTROINTESTINAL Duplication Cyst Omental/Mesenteric Cyst 16. DUPLICATION CYST SITES: May occur anywhere along the gastrointestinal tract But 1/3rd of cases involve the distal small bowel. The most frequent sites of duplication are the ileum, then oesophagus, stomach, duodenum and jejunum. Colonic and rectal duplications are rare. ETIOLOGY: Incomplete recanalisation at around 8 weeks gestation lined with GI Epithelium (may be adjacent mucosa /ectopic) 17. TYPES: Spherical /Tubular Most duplications do not communicate with the adjacent bowel, although there is a higher incidence of persistent communication in tubular anomalies PRESENTATION: Depends on the site of duplication and its size. Incidental ultrasound finding in the first few years of life. 18. Large cysts, especially those associated with the stomach or duodenum, may present with 1. Abdominal pain, 2. Obstruction 3. Vomiting 4. Lead point for intussusception or 5. A source of gastrointestinal bleeding from ectopic gastric mucosa. 19. IMAGING And TREATMENT Abdominal radiographs may show mass effect with displacement of adjacent bowel loops. Ultrasound demonstrates a simple hypoechoic cyst; if the characteristic 'gut-wall signature' TREATMENT :Surgical resection 20. Abdominal x-ray of a patient with a duplication cyst. Note the mass effect of the cyst pressing against the areas of colon (arrows). 21. Diagnosis of Multiple Gastric Duplication Cysts Causing Gastric Outlet Obstruction in a Pediatric Patient 22. Contrast-enhanced computed tomography image of the abdomen showing a well-circumscribed, low-attenuation fluid collection seen in relation to the greater curvature of the stomach with rim enhancement, suggestive of an intestinal duplication 23. Mesenteric/omental cysts (lymphangiomas) Developmental anomalies of the lymphatic system arising within the mesentery or omentum Presentation is similar to duplication cysts. Ultrasound is more likely to show a multiloculated cyst with thin septations than a simple cyst. Both require surgical resection. 24. Mesenteric cyst. CT demonstrating a large left-sided cystic abdominal mass with compression of the left kidney. Ultrasound showed multiple fine septations within the cyst 25. Lymphangioma has enhancing septa. Unlike in cystic peritoneal metastases, ascites is not a feature of lymphangioma. When you see a septated cystic lesion without ascites the most likely diagnosis is a lymphangioma 26. Notice that CT does not always appreciate the septations, although the specimen clearly shows multiple septations. 27. URINARY TRACT Renal /parapelvic Cyst Severe Hydronephrosis/ Pelviureteric junction obstruction Cystic Wilms Tumour (rare) Urachal Cyst 28. Parapelvic cyst 29. Severe hydronephrosis with proximal hydro ureter 30. Moderate hydronephrosis on right and severe on left 31. Urachal Cyst 32. ADRENALS Resolving adrenal heamorrhage Cystic neuroblastoma/ Ganglioneuroma(rare) 33. Resolving adrenal heamorrhage commonest cause of an adrenal mass Associated with perinatal stress, hypoxia, septicaemia and hypotension may be unilateral or bilateral Adrenal insufficiency is rare, even in bilateral cases. Ultrasound in the first few days of life usually demonstrates an avascular heterogenous adrenal mass that becomes cystic and smaller over the following weeks as clot retraction occurs 34. Day 2 35. Day 10 36. Cystic neuroblastoma/ Ganglioneuroma(rare) Over half of them arise in the adrenals, but 30% can arise from sympathetic tissue elsewhere in the abdomen Calcification has been noted to occur in over 50% of Cases Ganglioneuroma is a mature form of neurogenic tumour. Calcification helps in suggesting a diagnosis of neurogenic tumour 37. Adrenal ganglioneuroma with hepatic metastasis 38. PANCREATIC Pancreatic pseudocyst 39. Pancreatic pseudocyst well-known complication of pancreatitis fluid collections may occur within the pancreatic mass, or in the peripancreatic spaces, or elsewhere within the abdomen following either acute / chronic pancreatitis In acute pancreatitis, the pseudocyst contains enzyme-rich fluid and products of autodegradation of the pancreas in chronic pancreatitis the cyst is a consequence of duct obstruction. 40. Patients who have persistent abdominal pain or persistently elevated levels of pancreatic enzymes should be suspected of harbouring a pseudocyst one-third of pancreatic pseudocysts will resolve spontaneously 41. Adjacent to spleen with evidence of layering debris 42. Large cystic mass in the mid abdomen in the region of the pancreatic bed demonstrating echogenic material posteriorly, representing pancreatic necrosis. 43. Pancreatic pseudocyst Large septated cystic mass in the mid abdomen with nodular component. In the absence of history of pancreatitis it would be difficult to differentiate this from a cystic pancreatic tumour. 44. PELVIC Ovarian Cyst Teratoma/Dermoid Cyst Anterior Meningocele Abscess 45. Ovarian Cyst Cysts are fluid filled spaces within the ovary. very common and could be physiological / pathological, benign/ malignant Functional or physiological cysts are either follicular or of corpus luteum origin. Follicular cysts form when a follicle fails to rupture at midcycle leading to its continuous enlargement. Usually these cysts are asymptomatic and disappear without any intervention within one or two months Similarly a persistent corpus luteum might fail to disintegrate before menstruation and enlarge in size 46. Both follicular and luteal cysts could become haemorrhagic if bleeding occured within them leading to rapid increase in size and severe pain. they might cause severe pain only if they are large in size (>7 cm) and cause pressure symptoms or torsion of the whole ovary compromising blood flow when surgical intervention is indicated 47. Multiloculated ovarian cyst 48. A simple ovarian cyst on the right side of the uterus 49. Haemorrhagic ovarian cyst 50. Teratomas A teratoma is an encapsulated tumor with tissue or organ components resembling normal derivatives of more than one germ layer They therefore contain developmentally mature skin complete with hair follicles and sweat glands, sometimes luxuriant clumps of long hair, and often pockets of sebum, blood, fat, bone, nails, teeth, eyes, cartilage, and thyroid tissue. Typically their diameter is smaller than 10 cm, and rarely more than 15 cm. Real organoid structures (teeth, fragments of bone) may be present in ~ 30% of cases. 51. Pelvic Abscess A pus-filled cavity in the pelvis due to infection A pelvic abscess is the end stage in the progression of a genital tract infection and is frequently an unnecessary complication Treatment : Surgical drainage of abscess and dead tissue removal/ antibiotics 52. Abdominal computed tomography showed pelvic abscess (asterisk) and right tubo-ovarian abscess (arrow). 53. Conclusion Cysts may have different characteristics and origins Location, appearances, multi modality can help in the diagnosis 54. Mind teaser 55. Type 3 56. Type 1 57. Thanks