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Bizarre presentation of abdominal lymphangioma in children.

Though comparatively rare, abdominal lymphangiomas present a diagnostic challenge to family physicians and surgeons. Rekhi and associates' found that 75% of lymphangiomas arise in the neck, 20% in the axilla and 5% in the mediastinum, abdomen or groin. Patients with abdominal lymphangiomas present with symptoms and signs of an acute abdomen or intestinal obstruction or with chronic pain and abdominal distension.2 During my surgical training in England I encountered two cases of abdominal lymphangioma at two hospitals. Both were interesting cases that I would like to share with CMAJ readers. In the first case a 7-month-old girl who had been delivered at term and who had developed normally was admitted to hospital because of vomiting, diarrhea, a high temperature (40°C) and general irritability for 2 days. There was abdominal distension, rigidity and generalized tenderness. There was a suggestion of a mass to the left of the umbilicus. A laparotomy performed shortly after admission revealed that approximately 10 cm of the descending colon was surrounded by omentum wrapped around fluid-filled cysts. No other abnormality was found, so the mass was resected, and an endto-end anastomosis was performed. Recovery was uneventful. The lesion was reported to be a lymphangioma. The interesting features of this case are that there was no suggestionpreoperatively of peritonitis or intussusception, that at laparotomy there was no evidence of obstruction, that the tumour was subserosal and antimesenteric rather than submucosal or mesenteric, as in other reported cases,' and that the lymphangioma was in the descending colon in an infant, a circumstance not previously described. The second case involved a 5-year-old boy who presented with colicky central abdominal pain of 24 hours' duration. There was no nausea or vomiting. He appeared ill and flushed. His temperature was 37°C and his pulse rate 120 beats/min and regular. Abdominal examination revealed marked tenderness and guarding on the right side, particularly in the lower quadrant. An appendectomy was carried out the same afternoon. The appendix appeared to be inflamed. Histologic study of the appendix revealed only mild mucosal inflammation. The child's postoperative recovery was uneventful, and he was discharged home. He was readmitted to hospital 1 week after the appendectomy with right-sided abdominal pain and distension. He was mildly febrile. The leukocyte count was 15.0 X 109/1. During a 24-hour period of observation the mass increased in size. A provisional diagnosis of a huge right-sided hematoma or subphrenic abscess was made. Laparotomy revealed an enormous multilocular right-sided retroperitoneal cyst that extended from the diaphragm to the pelvis. It was quite adherent in parts; therefore, it was impossible to