Unusual Presentation of Giant Omental Cystic Lymphangioma Mimicking Hemorrhagic Ascites in a Child

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A 3.5-year-old boy presented with isolated abdominal pain and distension. Laboratory tests were normal. Abdominal ultrasound showed a large amount of ascites. Paracentesis yielded 1 L of blood-stained fluid; fluid cytology demonstrated mature lymphocytes. Magnetic resonance imaging revealed clumped bowel loops overlying the spine and the complete absence of ascites between bowel loops and around the liver. Bowel loops were displaced by intraperitoneal, multiloculated, septated T1- and T2-hyperintense soft tissue corresponding to venous blood (Fig. 1). Laparotomy revealed a giant cystic lymphangioma of the greater omentum (Fig. 2). The patient is doing well 24 months after surgery with no signs of recurrence.
Cystic lymphangioma is a benign, mesodermal, congenital tumor that stems from abnormal lymphatic tissue development. Complications from cystic lymphangioma include acute inflammatory episodes, infection, and intracystic hemorrhage (1). Microscopically, the cyst wall consists of a single layer of flattened epithelium with tissue spaces that may or may not contain blood-filled capillaries. The poorly supported blood vessels in cystic lymphangiomas may bleed and produce enlargement and discoloration of the cyst (2). The giant lesion and its blood-stained content can lead to difficulty distinguishing this lesion from hemorrhagic ascites (3). Bloody ascites during childhood is extremely rare, caused by only a limited number of disorders, including peritoneal tuberculosis, dengue fever, and malignancies.
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