Mesenteric cyst short information
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Here is a concise overview of mesenteric cysts based on authoritative surgical textbooks:
Mesenteric Cyst
Definition & Incidence
Rare benign intra-abdominal lesions arising within the mesentery. Incidence: 1 in 27,000 to 1 in 250,000 hospital admissions. Occur in both children and adults.
Classification / Types
| Type | Features |
|---|---|
| Chylolymphatic (most common) | Arise from congenitally misplaced lymphatics with no efferent connection; mostly in ileal mesentery; thin wall lined by flat endothelium; filled with clear lymph or chyle |
| Enterogenous | Derived from sequestrated intestinal diverticulum or gut duplication; thick wall lined by mucous membrane; content is mucinous |
| Traumatic | Post-injury origin |
| Hydatid | Parasitic origin |
Pathology
- Usually unilocular; may be multilocular
- Lined by a single layer of columnar (or flat endothelial) cells
- Typically large (average ~13 cm, ~2000 mL fluid)
- Up to 3% contain malignancy (usually sarcomatous); solid components raise malignancy risk
- Thought to arise from disrupted/obstructed lymphatics or congenital lymphatic malformations
Clinical Features
- Up to 45% found incidentally on imaging
- Chronic symptoms (nonspecific): abdominal pain/discomfort, anorexia, distension, nausea, vomiting, altered bowel habits
- Acute presentation: cyst rupture, bowel torsion, obstruction
- Most common symptom: pain (58%); most common sign: abdominal distension (68%)
- Abdominal mass detected on exam in up to 60% of patients
Classic Sign
Tillaux's sign: the mass is mobile only laterally (perpendicular to the root of the mesentery), unlike omental cysts which are freely mobile in all directions.
Diagnosis
- CT scan and ultrasound are the primary imaging modalities
- Appear as a homogeneous, fluid-filled mass without solid components in the mesentery
- Mesenteric cystic lymphangioma may appear as multiple cysts on imaging
Treatment
- Complete surgical excision (enucleation for benign; resection with clear margins for malignant)
- Can be performed laparoscopically or open
- Marsupialisation and simple aspiration have high recurrence rates — generally discouraged
- Chylolymphatic cysts: independent blood supply from adjacent bowel → enucleation possible without gut resection
- Enterogenous/duplication cysts: share blood supply with bowel wall → bowel resection and anastomosis required
- Small incidentally found cysts at laparotomy do not require resection unless complicated
- Usually cured by complete excision
Sources: Schwartz's Principles of Surgery 11e; Bailey & Love's Short Practice of Surgery 28e; Sleisenger & Fordtran's GI and Liver Disease
Upper gi hemorrhage classification, type,cause,sign symptoms, investigation management in short for mbbs neet pg students
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Upper GI Hemorrhage — MBBS / NEET PG Quick Reference
Definition
Bleeding proximal to the ligament of Treitz (esophagus, stomach, duodenum).
- Annual hospitalization: ~300,000/year (USA)
- Mortality: 3.5–7%
Classification
By Aetiology
| Type | Examples |
|---|---|
| Variceal | Oesophageal/gastric varices (portal HTN) |
| Non-variceal | Peptic ulcer, Mallory-Weiss tear, erosions, tumors, Dieulafoy, angiodysplasia |
By Onset
- Acute (overt, haemodynamically significant)
- Chronic (occult — iron deficiency anaemia, +ve FOBT)
Causes (with Frequency)
| Cause | % |
|---|---|
| Peptic ulcer (gastric/duodenal) ← MC cause | 38–40% |
| Gastric/oesophageal varices | 16% |
| Erosive oesophagitis | 13% |
| Upper GI tumours | 7% |
| Angiodysplasia / angiomas | 6% |
| Mallory-Weiss tear | 4% |
| Gastric/duodenal erosions | 4% |
| Dieulafoy lesion | 2% |
| Others (aortoenteric fistula, haemobilia, Cameron ulcer) | 2% |
Mnemonic: PEPTIC VAGUE — Peptic ulcer, Erosions, Portal hypertension (varices), Tumours, Inflammation (esophagitis), Cancer, Vascular (Dieulafoy, AVM), Aortoenteric, G-W tear, Ulcer (Cameron), etc.
Signs & Symptoms
Presenting Features
| Symptom | Details |
|---|---|
| Haematemesis | Vomiting fresh blood (active bleeding) or coffee-ground material (digested blood) |
| Melaena | Black, tarry, foul-smelling stool — blood digested in upper GI; ~50–80 mL blood needed |
| Haematochezia | Fresh rectal blood — usually lower GI, but ~15% can be from upper GI source (massive bleed) |
~50% present with haematemesis + melaena; ~30% haematemesis alone; ~20% melaena alone
Symptoms of Hypovolaemia
- Dizziness, syncope, thirst
- Cold clammy skin, pallor
- Oliguria
Signs on Examination
| System | Findings |
|---|---|
| Vitals | Tachycardia, hypotension, orthostasis |
| Skin | Pallor, spider naevi, palmar erythema, petechiae, purpura |
| Abdomen | Ascites, hepatosplenomegaly (portal HTN), epigastric tenderness |
| Rectal | Black/tarry stool on DRE |
Risk Stratification Scores ⭐ (High-yield for NEET PG)
1. Glasgow-Blatchford Score (GBS) — Pre-endoscopy, triage
Used at admission to identify low-risk patients (score 0–1 = safe for outpatient management).
| Parameter | Points |
|---|---|
| BUN ≥18.2 mg/dL | 2–6 |
| Hb <13 (men) / <12 (women) | 1–6 |
| SBP <110 mmHg | 1–3 |
| Pulse ≥100/min | 1 |
| Melaena | 1 |
| Syncope | 2 |
| Hepatic disease | 2 |
| Cardiac failure | 2 |
2. Rockall Score — Post-endoscopy, predicts rebleeding & mortality
| Variable | 0 | 1 | 2 | 3 |
|---|---|---|---|---|
| Age | <60 | 60-79 | ≥80 | — |
| Shock | No | Pulse>100 | SBP<100 | — |
| Comorbidity | None | — | Cardiac/other | Renal/liver/cancer |
| Diagnosis | MW tear/no lesion | All other | GI malignancy | — |
| Stigmata | None/dark spot | — | Blood/clot/vessel | — |
Score ≤2 = low risk; ≥8 = high mortality
3. Forrest Classification — Endoscopic stigmata of peptic ulcer bleeding
| Class | Finding | Rebleed Risk |
|---|---|---|
| Ia | Active arterial (spurting) | 90% |
| Ib | Active oozing | 50% |
| IIa | Visible vessel (non-bleeding) | 50% |
| IIb | Adherent clot | 25–30% |
| IIc | Flat pigmented spot | 7–10% |
| III | Clean base | <5% |
Endoscopic treatment indicated for Ia, Ib, IIa (and IIb - clot removal + treatment)
Investigations
Immediate
- CBC: Hb, Hct (may not reflect acute loss for 24–72 hrs), platelet count
- BUN/Creatinine: BUN rises disproportionately (blood protein breakdown) → BUN:Cr ratio >20 suggests upper GI source
- LFT + coagulation (PT/INR, aPTT) — assess liver disease
- Blood group & cross-match — prepare packed RBCs
- Vital signs + urine output monitoring
Diagnostic
| Investigation | Purpose |
|---|---|
| Upper GI Endoscopy (OGD) ← Gold standard | Identifies source, provides therapy; within 12–24 hours |
| CT angiography | If endoscopy non-diagnostic or fails; detects bleeding rate ≥0.3–0.5 mL/min |
| Mesenteric angiography | If active bleeding; therapeutic embolisation possible |
| Radionuclide scan (Tc-99m RBC) | Detects slow bleeding ≥0.1 mL/min |
Management
Step 1: Resuscitation (ABC)
- 2 large-bore IV lines (14–16 G)
- Normal saline bolus to maintain haemodynamic stability
- Blood transfusion: give pRBCs if Hb <7 g/dL (restrictive strategy); target Hb 7–9 g/dL
- Exception: Hb target 9–10 g/dL in cardiovascular disease or haemodynamic instability
- Platelets if <50,000/μL with active bleeding
- Consider endotracheal intubation if altered sensorium or active haematemesis (aspiration risk)
Step 2: Pharmacotherapy
| Drug | Use |
|---|---|
| IV PPI (omeprazole/pantoprazole) | Non-variceal bleed — high-dose (80 mg bolus + 8 mg/hr infusion); reduces rebleed |
| IV Octreotide/Somatostatin | Variceal bleed — decreases portal pressure |
| Terlipressin | Variceal bleed (reduces portal HTN) |
| IV Erythromycin 250 mg (30–60 min pre-endoscopy) | Prokinetic — clears stomach blood, improves endoscopic view |
| Antibiotic prophylaxis (ceftriaxone) | Cirrhotic patients with variceal bleed |
Step 3: Endoscopic Therapy (within 12–24 hrs)
- Non-variceal: Adrenaline injection + coagulation (heater probe/APC/clips)
- Variceal: Band ligation (oesophageal) or cyanoacrylate injection (gastric varices)
- Balloon tamponade (Sengstaken-Blakemore tube): temporary bridge in uncontrolled variceal bleed
Step 4: Radiological Interventions
- Angiographic embolisation — if endoscopy fails
- TIPS (Transjugular Intrahepatic Portosystemic Shunt) — refractory variceal bleed
Step 5: Surgery (last resort)
- Indications: failed endoscopy + radiology, exsanguinating haemorrhage
- Procedures: oversewing of ulcer, gastric resection, devascularisation
- Malignant lesions → appropriate surgical resection
Key Exam Points 🎯
| Fact | Value |
|---|---|
| MC cause of UGIB | Peptic ulcer (38–40%) |
| Minimum blood for melaena | ~50–80 mL |
| Gold standard investigation | Upper GI endoscopy (OGD) |
| Pre-endoscopy scoring | Glasgow-Blatchford Score |
| Post-endoscopy scoring | Rockall Score |
| Forrest Ia (spurting) rebleed risk | ~90% |
| Transfusion trigger (restrictive) | Hb <7 g/dL |
| Pre-endoscopy prokinetic | IV Erythromycin 250 mg |
| Variceal bleed drug | Octreotide / Terlipressin |
| Balloon tube for varices | Sengstaken-Blakemore tube |
Sources: Goldman-Cecil Medicine 2e; Schwartz's Principles of Surgery 11e; Bailey & Love's 28e
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