Duodenal duplication cysts.

Abstract

CASE HISTORY A 17-year-old girl presented with a 3-month history of severe, episodic, epigastric pain that radiated to her upper back. The pain was accompanied by nausea and occasional vomiting, which was nonbilious and nonbloody. The pain initially occurred once weekly but progressed to two times a week. The pain was described as sharp, often following a meal, and unrelated to bowel movements. The patient reported no constipation or diarrhea. The pain did not awaken her at night. There had been a documented 6-kg weight loss. There was no history of abdominal trauma. The patient's medical history was unremarkable. Her family history revealed that her maternal grandmother had diverticulitis, and her mother and paternal uncle had had cholecystectomies because of cholecystitis. There was no family history of pancreatic disease. Results of initial blood screening studies were normal. The patient was referred to our service after a contrast radiographic study of her upper gastrointestinal tract and an abdominal computed tomography scan revealed a mass within the third portion of the duodenum. Physical examination showed a well-developed, well-nourished teenager (body mass index, 75%–85%) who was in no distress. Vital signs were normal. Her sclerae were anicteric. Her abdomen was not distended but was tender in the low epigastrium on deep palpation. There was no hepatomegaly or splenomegaly, and no masses were palpated. There were no abdominal bruits or friction rubs. There was no active anal disease, and digital examination of the rectum revealed a normal rectal vault with no stool present. She had no peripheral edema. Upper intestinal endoscopy and endoscopic ultrasound examination of the duodenum were performed (Fig. 1, A & B).FIGURE: (A) Third portion of the duodenum. (B) Endoscopic ultrasound.What is your diagnosis? (A) Third portion of the duodenum. (B) Endoscopic ultrasound. ANSWER: The endoscopic ultrasound demonstrated a round intramural (subepithelial) lesion in the third portion of the duodenum (Fig. 1B) adjacent to the inferior vena cava. The lesion was anechoic, and the margins measured 3.5 cm in maximal diameter. The patient was taken to the operating room, and a duodenal duplication cyst was excised. COMMENT Duplication cysts are hollow, epithelial-lined, spherical or tubular structures that are attached to some portion of the gastrointestinal tract, most frequently the distal ileum (1). Duodenal duplication cysts account for only 4% to 5% of intestinal duplications (2). They always contain gastric or duodenal epithelium and occasionally may contain pancreatic or even respiratory epithelium (3). Vertebral anomalies are seen in 50% of cases because the cyst may interfere with anterior fusion of the vertebral mesoderm (4,5). These patients usually have symptoms of partial gastric outlet obstruction, such as nausea, vomiting, epigastric pain, and abdominal distention (6). Physical examination and laboratory studies usually reveal no abnormalities. Sonography and computed tomography scan can confirm the cystic nature of the mass. On ultrasonography, duodenal duplication cysts appear as anechoic masses with strong back wall echoes and sound through transmission (7). Duodenal duplication cysts can be recognized on computed tomography scan as discrete, fluid-filled structures abutting the medial wall of the descending duodenum (8). The finding of a cystic mass that is contiguous with the duodenum but separate from the biliary system and the pancreas is suggestive of a duodenal duplication cyst. Treatment is complete surgical excision.