Mesenteric volvulus due to mesenteric cyst

A 52-year-old woman attending the emergency room for left abdominal pain and vomiting. 17,10 thousand/mm3 stand out and an abdominal ultrasound was requested with the suspicion of diverticulitis. A mesenteric cystic lesion is seen. An enhanced computed tomography (CT) is performed, confirming the existence of a mesenteric cyst that conditions a rotation of the mesenteric vessels ("whirl sign"), concluding our diagnosis as mesenteric volvulus due to a mesenteric cyst.

Mesenteric cysts are a rare cause of abdominal pain and have a wide range of underlying causes, among which the following stand out: lymphatic, mesothelial, enteric, urogenital, dermoid or pseudocysts, and they can occur anywhere in the mesentery, from the duodenum to the rectum. Cystic peritoneal lesions within the abdominal cavity, have to be accurately diagnosed for proper management. It is important to determine the organ of origin, and if does not arise from an abdominopelvic solid organ, probably it will originate from the mesentery or omentum . US and CT are helpful in diagnosing it. Although the US is adequate to demonstrate the cystic nature of the lesion and volvulus, CT is helpful in further characterizing the lesion, denoting extent and relationship of the mass with surrounding bowel loops and demonstrating the midgut rotation. The “whirlpool sign” has been found specific for volvulus and small bowel obstruction. This sign depicts anatomic features that can compromise circulation to the bowel and it appears as a twist of bowel wrapping around a single constrictive focus of mesentery that may contain intestinal blood vessels1.

Mesenteric cysts, despite being benign entities, can condition complications that require urgent surgical intervention. The whirl sign plus specific symptomatology are keys for the early management of the patient, avoiding delays that compromise the intestinal viability. CAPTION A. Axial enhanced CT where we see the “whirlpool sign” (red circle) in mesenteric vessels suggesting mesenteric volvulus. B. Mesenteric cyst (red arrows) with mesenteric vessels congestion (on the left corner ultrasound detail of the mesenteric cyst). C. Coronal reconstruction showing mesenteric “whirl sign” (red arrow).

- Arraiza M, Metser U, Vajpeyi R, Khalili K, Hanbidge A, Kennedy E et al. Primary cystic peritoneal masses and mimickers: spectrum of diseases with pathologic correlation. Abdom Imaging. 2015 Apr,40(4):875-906. - Prabhu S, Anand R, Narula M, Shetty G, Ud