Congenital enteric duplication cyst; report of a case diagnosed roentgenologically.

Abstract

Preoperative roentgen diagnosis of the uncommon congenital duplication cyst of the small bowel is rarely made. With growing awareness of the nature of this anomalous malformation, radiologists apparently are learning to demonstrate its presence with increasing frequency. Kump, Jorgens and Rigler (4) have reported and discussed the diagnostic and prognostic significance of roentgenologically demonstrable ectopic gastric mucosa in a congenital small bowel diverticulum. In the following case, the demonstration by spot-films and routine radiographs of ectopic gastric rugae lining a saccular, mobile out-pocketing of the intestinal wall led to the correct preoperative diagnosis. Case Report G. M., a 3-year-old white male, was completely well until one day prior to his admission to Sarah Morris Hospital of Michael Reese Hospital Medical Center, May 2, 1957, because of increasing pallor, anorexia, nausea, vomiting, and profuse rectal bleeding. Gross bleeding from the rectum continued for twenty-four hours after admission and then ceased completely. Each bloody bowel movement was preceded by crampy, generalized abdominal pain. No history of abnormal bleeding tendency was elicited. On admission, the pulse was 104; temperature 102° F; blood pressure, 90 mm. Hg systolic and 20 mm. Hg diastolic; hemoglobin 6.7 gm. per 100 ml.; hematocrit 19 per cent. The white blood cell count was 14,500, with a normal differential count. The abdomen was soft, flat, and nontender; bowel sounds were normal. There were no unusual palpable masses. The bleeding time was 3.5 minutes (Duke) and the clotting time was 8.5 minutes (Lee-White). Barium enema examination failed to disclose the presence of a polyp or of an intussusception. An upper gastrointestinal examination showed no abnormality. On May 11, 1957, small intestinal examination revealed an unusual group of mucosal folds adjacent to the lower jejunum or proximal ileum. These folds resembled gastric rugae (Figs. 1–3). On fluoroscopic observation and spot-films the spherical pouch containing the rugal folds was found to be mobile; it was attached to the bowel by a stalk and showed peristaltic activity (Fig. 3). The diagnosis of Meckel's diverticulum or duplication cyst lined with ectopic gastric mucosa was made. On May 17, 1957, exploratory laparotomy was performed. Approximately 40 cm. from the ileocecal valve, a saccular soft mass arose near the mesenteric border of the ileojejunal portion of the small bowel. The mass measured 6.0 cm. in diameter. The lumen of the pouch communicated with the small bowel by means of an orifice measuring 3.0 cm. in diameter. Several engorged blood vessels passed over the smooth but hyperemic serosal surface (Fig. 4). Operation: A segment of small bowel with attached duplication cyst was excised and direct anastomosis of the ends of the intestine effected. The postoperative course was uneventful and at the time of this report the child is well.