Endoscopic Treatment of Colonic Duplication Cyst

Abstract

Introduction: Colonic duplication cyst is a rare congenital abnormality commonly presenting before age of 2 years. We here present a case of endoscopic ultrasound (EUS) guided diagnosis and treatment of colonic duplication cyst. Case report: A 42-year-old African-American female underwent colonoscopy for evaluation of constipation. She denied any associated history of anorexia, weight loss or hematochezia. Her colonoscopy showed a large submucosal lesion at the hepatic flexure. The lesion was tattooed by India ink and the patient was referred to advance endoscopist for further evaluation. Meanwhile her CT scan of abdomen with contrast was done which was showed a small cystic lesion around splenic flexure. On repeat Colonoscopy with endoscopic ultrasound (EUS), a tattooed subepithelial lesion was seen in the hepatic flexure (Figure 1). On EUS, a 14 mm anechoic lesion lined by mucosa consistent with duplication cyst was seen (Figure 2). The mucosa was then snared exposing the cyst (Figure 3). The patient was discharged home with outpatient follow-up. Pathologic evaluation showed normal colonic mucosa without any dysplastic changes.Figure: Intraluminal mass at hepatic flexure (A) and transparent appearance (B).Figure. 12: MHz EUS images showing subepithelial anechoic lesion lined by mucosa.Figure: Fluid drainage after unroofing the cyst cavity (A) and flattening of lesion after drainage (B).Discussion: Enteric duplication cysts are rare entity encountered in pediatric age group and extremely rare in adults. Most common site of enteric duplication cyst is Ileum followed by ileocecal valve with colonic duplication cyst comprising only 6.8% in one case series. These cysts commonly occur on the mesenteric side of bowel and share a common blood supply with native bowel. The clinical presentation varies in patients ranging from abdominal pain, volvulus, intussusception, ischemic bowel, obstruction, and constipation. CT scan and US abdomen are helpful in making the diagnosis of duplication cyst. US may reveal fluid filled complex cyst with internal echoes. They are also characterized by typical inner echogenic mucosa and outer hypoechoic muscle layer. Cases of malignant transformation have rarely been reported in literature including one case of the metastatic disease. Surgical resection is classically being done for the cyst as they are found incidentally or intraoperatively. Effective drainage was established by hot snare resulting in resolution of patient's symptoms. Duodenal duplication cysts have been effectively drained and treated endoscopically commonly using needle knife papillotomy with good reported long-term outcomes. This case is the first reported case of EUS guided drainage of colonic duplication cyst.