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CASE REPORT
Year : 2020  |  Volume : 8  |  Issue : 2  |  Page : 98-100

Primary heterotopic mesenteric ossification


Department of Digestive Surgery, Gastroenterology and Hepatology Teaching Hospital, Medical City, Baghdad, Iraq

Date of Submission24-Jul-2020
Date of Acceptance29-Aug-2020
Date of Web Publication24-Feb-2021

Correspondence Address:
Dr. Raafat Alturfi
Department of Surgery, Gastroenterology and Hematology Teaching Hospital, P.O. Box 15200, AL-Yarmouk, Medical City, Baghdad
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_30_20

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  Abstract 

Heterotopic ossification (HO) is the presence of bone in nonossifying tissue. Mesenteric HO usually results from previous abdominal trauma or surgery. This is a case report of 87-year-old lady who presented with subacute intestinal obstruction, she had neither previous history of abdominal trauma nor surgery. On exploration, there was spiral ossified tissue trapping small bowel that was removed and the condition resolved completely. As long as to our knowledge, this is the first reported case of intra-abdominal Heterotopic ossification without previous cause in English articles. HO should keep in mind in any ossified peritoneal lesion even without previous surgery or trauma.

Keywords: Heterotopic ossification, intestinal obstruction, myositis ossificans


How to cite this article:
Alturfi R, Atallah M. Primary heterotopic mesenteric ossification. Saudi Surg J 2020;8:98-100

How to cite this URL:
Alturfi R, Atallah M. Primary heterotopic mesenteric ossification. Saudi Surg J [serial online] 2020 [cited 2021 Apr 15];8:98-100. Available from: https://www.saudisurgj.org/text.asp?2020/8/2/98/310119


  Introduction Top


Heterotopic ossification (HO) is the presence of bone in nonossifying tissue. It is a very rare condition and usually, patients are either asymptomatic[1] or presented with a spectrum of symptoms ranging from slight abdominal pain to intestinal obstruction.[2]

The etiology of this condition is either hereditary which is called myositis ossificans progressiva or acquired which is usually caused by trauma or surgery.[3]

As long as to our knowledge, there was no reported case of intra-abdominal HO without an obvious cause in English literatures, we here reported a case of primary mesenteric HO that causes subacute intestinal obstruction requiring explorative laparotomy to resolve.


  Case Report Top


A 87-year-old female presented with abdominal pain, vomiting, abdominal distention, and absolute constipation of 1-week duration. There was neither history of abdominal surgery nor trauma. On examination, there was abdominal distention with visible peristalsis, normal inguinal orifices. The abdominal plain X-ray showed dilated small bowel loops with calcified lesion seen in the pelvic cavity that was given the suspicion of vesicle stone [Figure 1].
Figure 1: Plain radiograph shows the osseous lesion

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Her renal indices were slightly elevated which was return back to normal after proper fluid therapy.

Abdominal computed tomography (CT) scan showed multiple small bowel fluid levels without an obvious cause of obstruction with spiral shape calcified lesion at the pelvic cavity [Figure 2].
Figure 2: (a and b) Abdominal computed topography showed calcified spiral

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After a few hours of conservative management, the patient was explored by diagnostic laparoscopy which was revealed a spiral bony lesion in the peritoneal cavity freely mobile causing small bowel trapping [Figure 3], the lesion was extracted by mini midline incision [Figure 4].
Figure 3: Laparoscopic view of the lesion

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Figure 4: (a and b) Operative photograph of the lesion

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The small bowel was released by cutting a small piece of this bony lesion without the need for resection of the small bowel and the bony lesion was removed completely. The postoperative period was uneventful, she was resumed oral intake after 6 h and discharged home after 2 days. Six months later, the patient visited the clinic complaining of abdominal pain, anorexia, and weight loss. Abdominal CT scan revealed multiple enhanced liver lesions without recurrence of the calcified lesion. The diagnosis was made as carcinoma of unknown origin nor related to the HO, the patient succumbed after few weeks.

The histopathological examination was showed fibrofatty tissue composed of well-defined hyalinized nodules with calcification and fibrosis [Figure 5].
Figure 5: (a and b) The histopathology showed hyalinized nodule with calcification

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  Discussion Top


HO is a benign metaplastic condition usually discovered incidentally or presented with various symptoms. Wilson et al. first described it in 1999 showing the formation of bone tissues that normally do not ossify.[4] Usually, this lesion affecting the mesentery and seldom the omentum, peritoneum, or other intra-abdominal organs.[5],[6]

The pathogenesis of this condition is not clearly defined, but the literatures point to a four-stage process of osteogenic induction. It begins with a form of primary insult and within an ideal environment leading to an inappropriate differentiation of mesenchymal cells into osteoblastic stem cells in response to still unidentified inducing agents.[3]

Risk factors for HO can be classified into trauma which is attained from surgical trauma, i.e., operations, fractures, dislocations, burns, and contusions. Risk factors for HO can be classified into trauma whichis attained from surgical trauma, i.e., operations, or fractures,dislocations, burns, and contusions. Injury to the brain and/or spinal cord, injection of central nervous system forpolio and tetanus. lastly genetic predisposition conditions such as fibrodysplasia ossificans progressive, progressive osseous heteroplasia and Albright's hereditaryosteodystrophy are another well known causes.[4]

In our case, there was no identified cause neither history of trauma or surgery nor hereditary illness.

The most clinical presentation is intestinal obstruction, mainly in cases affecting the mesentery, with the symptoms including abdominal pain, nausea, vomiting, obstipation, and abdominal distention (as in the current case), while in cases affecting mainly the omentum, they presented usually with intestinal perforation, peritonitis, and enterocutaneous fistula. It can also be an incidental finding in asymptomatic patients.[7],[8]

Laboratory tests demonstrate raised alkaline phosphatase due to osteoblastic activity which is a sensitive indicator for HO.[9]

Diagnosis is confirmed by using a CT scan, which reveals multiple linear branching opacities with trabecular ossifications.[9] In our case, the CT scan showed a spiral shape ossified mass in the pelvis.

The surgical intervention is usually performed for symptomatic cases or for the treatment of complications, like in our case as she presented with intestinal obstruction. Medical management advocates the use of anti-inflammatory drugs, diphosphonates, and radiotherapy which may prove useful in the prevention of recurrence, while anti-inflammatory drugs also reduce the incidence of the disease. There are data which support the use of nonsteroidal anti-inflammatory drugs and diphosphonates in preventing the formation of HO.[2]

HO has a good prognosis, without any malignant potential, but shows the tendency for recurrence and can also contribute to morbidity due to bowel obstruction,[6] so follow-up is required for early detection and treatment of recurrence.

In summary, heterotopic mesenteric ossification is a rare disorder, which can develop after an abdominal operation or as a spontaneous condition without triggering factor, as in our case, and cause severe complications such as bowel obstruction and even intestinal perforation. The characteristic imaging features of heterotopic mesenteric ossification should be kept in mind, which could lead to the correct preoperative diagnosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Balboni TA, Gobezie R, Mamon HJ. Heterotopic ossification: Pathophysiology, clinical features, and the role of radiotherapy for prophylaxis. Int J Radiat Oncol Biol Phys 2006;65:1289-99.  Back to cited text no. 1
    
2.
Koolen PG, Schreinemacher MH, Peppelenbosch AG. Heterotopic ossifications in midline abdominal scars: A critical review of the literature. Eur J Vasc Endovasc Surg 2010;40:155-9.  Back to cited text no. 2
    
3.
Shehab D, Elgazzar AH, Collier BD. Heterotopic ossification. J Nucl Med 2002;43:346-53.  Back to cited text no. 3
    
4.
Wilson JD, Montague CJ, Salcuni P, Bordi C, Rosai J. Heterotopic mesenteric ossification ('intraabdominal myositis ossificans'): Report of five cases. Am J Surg Pathol 1999;23:1464-70.  Back to cited text no. 4
    
5.
Di Paolo N, Sacchi G, Lorenzoni P, Sansoni E, Gaggiotti E. Ossification of the peritoneal membrane. Perit Dial Int 2004;24:471-7.  Back to cited text no. 5
    
6.
Zamolyi RQ, Souza P, Nascimento AG, Unni KK. Intra-abdominal myositis ossificans: A report of 9 new cases. Int J Surg Pathol 2006;14:37-41.  Back to cited text no. 6
    
7.
Shi X, Zhang W, Nabieu PF, Zhao W, Fu C. Early postoperative heterotopic omental ossification: Report of a case. Surg Today 2011;41:137-40.  Back to cited text no. 7
    
8.
Yushuva A, Nagda P, Suzuki K, Llaguna OH, Avgerinos D, Goodman E. Heterotopic mesenteric ossification following gastric bypass surgery: Case series and review of literature. Obes Surg 2010;20:1312-5.  Back to cited text no. 8
    
9.
Kao HW, Liou CH, Chang WC, Yu CY, Chen CY. Imaging features of heterotopic mesenteric ossification: A case report and literature review. Chin J Radiol 2005;30:55-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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