Retroperitoneal gastric duplication mimicking a prenatal adrenal cyst.

Abstract

Duplications of the gastric tract are made up of a wide variety of masses throughout the gastrointestinal tract. They may have tubular or cystic morphology. Some duplications are associated with malformations, especially those located in the thorax, which can be associated with intestinal atresia, and malformations of the urinary tract or vertebras (Lund 2012). Duplications in the alimentary tract are found in 1:10 000 live births, 75% of which have a cystic appearance and they are more common in females (Ford et al. 2004). They develop increasingly in the major curvature of the stomach without having any kind of connection between them (Kuraoka et al. 2004; Davies et al. 2008). Sixty percent of gastric duplications are diagnosed during the first year of life; 40% during the neonatal period as a palpable mass accompanied by vomiting and weight loss. We present the case of a nursing baby girl, who had a prenatal diagnosis of kidney cyst and presurgical diagnosis of adrenal cyst; in contrast, the pathological diagnosis finally confirmed it as gastric duplication. Prenatally an intrabdominal cyst was diagnosed, located in the left retroperitoneum. Antenatal diagnosis at 20 weeks of gestation was a left kidney cyst. The lesion was followed up until birth. The patient was born at 39 weeks of gestation, 3.240 kg, via spontaneous vaginal birth. At birth, an ultrasonographic control confirmed there was a 2 × 1.7 cm cystic lesion between the upper pole of the left kidney and the adrenal gland (Fig. 1A). Measurement of urinary catecholamines (collected in 24 h) showed normal range for all parameters (adrenaline 0.0 nM [Normal 0.0–123], noradrenaline 77 nM [Normal 0.0–504] and dopamine 223 nM [Normal 0.0–3237]). Ultrasonographic control at 2 months revealed lesion growth to 3.7 × 1.9 cm. A magnetic resonance imaging (MRI) was performed, confirming a left suprarenal mass of 4 × 2.4 cm, oval-shaped and with well-defined contours deforming and marking the upper pole of the left kidney (Fig. 1B). No associated malformations were observed in these studies. The patient was asymptomatic at all times, with no episodes of emesis or symptoms related to intestinal obstruction. Physical examination revealed no diseases. Four months after birth, and due to the progressive growing of the lesion, we had diagnostic doubts, so we decided to carry out a laparotomy for cystic resection. A left transversal laparotomy was carried out, and a left adrenalectomy was made to access the lesion at the retroperitoneal level. The adrenal gland could not be preserved due to it being completely stuck onto the cyst. Although it did not depend on the gland, a cystic neoplasm was found with a maximum diameter of 5 cm, with well-defined contours, no adherence to planes and there was no connection to any other organ (it was an independent location). After resection, it showed an ovoid formation, pink surface, smooth and shiny, 11 g, 4 × 2.1 cm (Fig. 1C). Upon opening, the cavity wall was smooth and pink, with a maximum thickness of 2 mm, containing serous liquid, 2.5 × 1.5 × 0.3 cm suprarenal without any alterations. The histopathological study confirmed a wall-cyst of gastric duplication with the three layers: mucosa, muscular and serosa (by means of hematoxylin and eosin staining, × 60) and the cystic lining could be seen with gastric mucosal glands (by means of Periodic acid–Schiff staining, × 100). The pathology diagnosis was gastric duplication cyst with complete parietal structure and moderate vascular-lymphatic dilatation. No dysplasia or inflammation was observed. The adrenal gland showed no histological alterations (Fig. 1D,E). Preoperative diagnosis is very complex. Prenatal diagnosis frequency is increasing, those most detected being intra-abdominal cysts. In the ultrasonography, these lesions are visible as anechoic cysts, unless they show ulceration or bleeding. They have a thicker wall, of about 3 mm wide, unlike the mesenteric cysts, ovaries or omentums which have a simpler wall. Complementary tests such as ultrasonographies, gastrointestinal transit, computed tomography (CT) and MRI should be made when the results are not clear. Gastrointestinal transit helps us know if there is a connection with the digestive tract (Lund 2012). For patients whose preliminary study classifies these kinds of tumors as non-functional, it is necessary to distinguish between a malignant and a benign neoplasm. The monitoring recommendation could change depending on the size of the lesion and its growth (Terry et al. 2007; Pachl et al. 2012). In conclusion, antenatal diagnosis of the gastric duplication contributes to studies and early excision, thereby avoiding complications that appear within the first years of a child's life. The differential diagnosis during the prenatal period must include: ovarian cysts, digestive tract duplication, mesenteric cysts, gastric duplication and . In case of diagnostic doubt, a laparoscopy is suitable. In some cases the laparoscopy is both diagnostic as well as therapeutic (Ford et al. 2004; Onol et al. 2009). None.