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Johns Hopkins Hospital Baltimore, MD 21287
Heterotopic mesenteric ossification is an uncommon disorder that may be misdiagnosed, which may lead to serious complications. We describe the radiographic findings and key features to prevent future misdiagnosis of this rare process.
A 50-year-old man sustained a stab wound to the left flank in 1998 that required nephrectomy and left colon resection with a colostomy. One year later, the patient had a takedown of his ostomy and subsequently developed multiple enterocutaneous fistulas. In February 2000, the patient elected to have surgery for closure of the fistulas. Preoperative abdominal radiographs showed a radiodensity in the mesentery that was interpreted as barium extravasation (Fig. 4A). Operative findings included heterotopic bone in the shapes of wishbones and other unusual configurations just below the fistulas and within the anterior surface of the mesentery. Several portions of bone, which had obstructed bowel in that region, were resected. Unresectable bone fragments were noted by the radiologist on the postoperative contrast-enhanced CT scans, but these fragments were also interpreted as barium extravasation (Fig. 4B).
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Intraabdominal heterotopic ossification has been known to occur in laparotomy scars and with mucinous epithelial tumors [1]. However, bone formation in the mesentery, unassociated with mucinous neoplasms, is extremely rare and is of unknown cause. In the most recent review of this disorder, Wilson et al. [2] concluded that heterotopic mesenteric ossification is most likely "an exuberant reaction to trauma in a predisposed individual."
To our knowledge, only nine cases of heterotopic mesenteric ossification have been reported [2,3,4]. In these reports, all patients were middle-aged to elderly men (age range, 43-80 years; mean age, 61 years) who developed small-bowel obstruction after one or more abdominal operations for nonneoplastic disease [2]. In most cases the mesenteric ossification was the direct cause of the obstruction. None of the reported cases documented the radiographic features of this disorder.
This entity should be recognized radiologically and distinguished from dystrophic calcification, osseous neoplasia, or, as in this patient, barium extravasation, for two important reasons. First, heterotopic mesenteric ossification may cause bowel obstruction and even death because of intestinal perforation. Second, heterotopic bone formation tends to recur [4]. Thus, after surgical resection of all evident bone fragments, recurrence may continue to cause complications.
There are some clues to recognizing this entity. A trabecular architecture evident on radiographs is highly suggestive of ossification and is uncharacteristic of barium extravasation or dystrophic calcification. Also, the presence of mature trabeculae distinguishes heterotropic mesenteric ossification from osseous neoplasia. Furthermore, if the unusual trabecular pattern remains unchanged on radiographs before and after a barium contrast study, it is extremely unlikely that the radiodensity is caused by extravasated barium. Finally, preoperative CT can be performed, which may provide confirmatory evidence of any suspicious trabecular pattern seen on abdominal radiographs.
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