PMC5779771_01
PMC5779771_02
Abdominopelvic CT on admission shows a homogeneous, 10.1 x 4.9 cm right adnexal mass, which has an attenuation of 60 Haunsfield units, characteristic of clotted blood from a hematoma. The patient had been administered warfarin until 1 week earlier for atrial fibrillation, but had no history of abdominal trauma and had no abdominal ecchymoses on physical examination. Follow-up abdominopelvic CT performed 1 month after admission revealed marked shrinkage of adnexal mass to 5.4 x 2.9 cm, highly consistent with resorption of a hematoma.
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F1
Abdominal ultrasound revealed massive ascites and a 10.1 x 4.9 cm right adnexal mass, which on abdominopelvic computerized tomography (CT) had an attenuation of 60 Haunsfield units, characteristic of a hematoma (Fig. 1).
Endoscopic findings in a female octogenarian with primary intestinal lymphangiectasia. (A) Close-up view with ileal intubation during colonoscopy demonstrates numerous, small, creamy white, punctae consisting of dilated lymphatic vessels filled with lymphatic fluid throughout the terminal ileum. (B and C) Far-away (B) and close-up (C) views at push enteroscopy demonstrate numerous, small, creamy white, punctae consisting of dilated lymphatic vessels filled with lymphatic fluid throughout distal duodenum and proximal jejunum.
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F2
Terminal ileal intubation during colonoscopy revealed numerous, creamy white, punctate ("snowflake") mucosal lesions, highly consistent with intestinal lymphangiectasia (Fig. 2A). Push enteroscopy performed by the same endoscopist (MSC) also demonstrated numerous similar mucosal lesions in distal duodenum/proximal jejunum, without visible lesions in proximal duodenum (Fig. 2B and C).
Histopathology and immunohistochemistry of lymphangiectasia. (A) Conventional hematoxylin and eosin stain. Medium-power photomicrograph of terminal ileal biopsy taken during ileal intubation at colonoscopy demonstrating a single villus on the mucosal surface containing an extremely dilated vascular space lined by uninflamed epithelium, with histology highly consistent with a lacteal vessel. (B and C) Immunohistochemistry of lymphangiectasia. High-power photomicrographs of terminal ileal biopsy taken during ileal intubation shows immunohistochemical staining with antibodies to D2-40 (podoplanin) avidly binding in cytoplasm of lymphatic endothelium (B), and immunohistochemical staining with antibodies to ERG avidly binding to the nucleus of lymphatic endothelium (C), demonstrating that the vessels are lacteals. Neither antibody demonstrates affinity to ileal epithelial glands.
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F3
Histological analysis of colonoscopic biopsies of terminal ileum and of enteroscopic biopsies of distal duodenum demonstrated dilated lacteals within tips of intestinal villi (Fig. 3A), confirmed as dilated lacteals by 2 immunohistochemical markers for lacteal endothelium (Fig. 3B and C). Ultrastructural analysis of one of the dilated lymphatic channels (seen in Fig. 3A) contained multiple structures with shape, size, and structure consistent with chylomicrons (Fig. 4).