An Unusual Cause of Recurrent Vomiting

Abstract

Question: A 28-year-old man was admitted for postprandial epigastric pain, and chronic vomiting for 6 months, associated with a 6-kg weight loss. He had no relevant medical or family history. Physical examination and laboratory workup were normal. An anechoic lesion located in the second part of the duodenum wall was revealed on abdominal ultrasound imaging, and a submucosal mass was diagnosed in the same region, using an upper endoscopy technique (Figure A). Furthermore, endoscopic ultrasound imaging (Figure B) and magnetic resonance imaging with dynamic sequences (Figure C) showed a 25 × 26-mm cystic duodenal lesion. There was no connection between the lesion and the biliary and pancreatic ducts, which seemed to be normal. What is your diagnosis? How should the patient be treated? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Endoscopic ultrasound imaging showed an anechoic duodenal lesion with an inner echogenic ring and an outer hypoechoic ring. Abdominal magnetic resonance imaging found a consistent appearance of a duodenal cyst protruding into the duodenal lumen, in the second part of the duodenum. These findings are specific to an enteric duplication cyst. We performed an endoscopic treatment of the cyst. The cyst's roof was first punctured using a needle-knife papillotome. The wall of the cyst was then incised using a polypectomy snare. Pathologic examination showed a double muscle layer with both mucosal and submucosal layers (Figure D), confirming the diagnosis of duodenal duplication cyst. The patient was discharged of hospital 24 hours later. Follow-up was uneventful. Duodenal duplication cyst is a rare congenital malformation.1Chen J.-J. Lee H.-C. Yeung C.-Y. et al.Meta-analysis: the clinical features of the duodenal duplication cyst.J Pediatr Surg. 2010; 45: 1598-1606Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar, 2Antaki F. Tringali A. Deprez P. et al.A case series of symptomatic intraluminal duodenal duplication cysts: presentation, endoscopic therapy, and long-term outcome (with video).Gastrointest Endosc. 2008; 67: 163-168Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Although exceptional malignant tumor developments have been described, duodenal duplication is usually associated with a good prognosis. Before the era of therapeutic endoscopy, surgical resection was performed in symptomatic patients, with significant morbidity. Various straightforward, safe, and effective endoscopic techniques have since been described, including cyst puncture, snare resection, and cyst needle aspiration/ligation, as suggested by Gjeorgjievski et al.3Gjeorgjievski M. Manickam P. Ghaith G. et al.Safety and efficacy of endoscopic therapy for nonmalignant duodenal duplication cysts.Medicine (Baltimore). 2016; 95: e3799Crossref PubMed Scopus (12) Google Scholar Long-term clinical outcomes are excellent, making therapeutic endoscopy a valid, minimally invasive alternative to surgical resection.