|Year : 2015 | Volume
| Issue : 2 | Page : 29-31
Isolated duodenal duplication cyst: A review
Akhlak Hussain1, Mohinder Singh2, Sarabjit Singh2
1 Department of Surgery, Safdarjang Hospital, New Delhi, India
2 Department of Surgery, Rajindra Hospital, Patiala, Punjab, India
|Date of Web Publication||19-May-2016|
Safdarjang Hospital, New Delhi
Source of Support: None, Conflict of Interest: None
Duodenal duplication cyst is a rare condition but can be associated with serious complications. Keeping this in mind, we are reviewing the topic and presenting a rare case report of isolated duodenal duplication cyst emphasizing the importance of computed tomography scan in reaching the diagnosis.
Keywords: Duodenum, duplication cyst, pediatric
|How to cite this article:|
Hussain A, Singh M, Singh S. Isolated duodenal duplication cyst: A review. Niger J Surg Sci 2015;25:29-31
| Introduction|| |
Gastrointestinal tract duplication is a congenital abnormality. It has well-developed smooth muscle lining. The epithelial lining represents some portion of the alimentary tract. The ileum is the most frequent site. Only 5-10% of all gastrointestinal duplications are duodenal. Mostly, in the pediatric group rare in adults. Most of them are associated with other anomalies. Mostly, they are attached to nearby structures. Completely isolated duodenal duplication is very rare. Therefore, we tried to review the topic while presenting this rare case report of isolated duodenal duplication cyst diagnosed by computed tomography (CT) scan.
| Case report|| |
A 14-year-old child had presented with our emergency with the complaints of recurrent pain in the umbilical region, nausea, and constipation for 1½ years. Previous episodes were relieved by medications locally. The parents narrated that initially a local surgeon confused this pain with a bilateral small hernia and did herniotomy. However, the pain was recurred same as before many times and relieved by medications. The patient was stable with normal vitals. On examination, the abdomen was soft, no mass palpable and bowel sound were decreased. Per rectal examination was normal and empty. Hemogram, renal function tests, blood sugar, and serum electrolytes were normal. Roentgen examination of the abdomen was normal. Ultrasound abdomen revealed an enteric duplication cyst about 3 cm × 4 cm in size. We proceed for contrast-enhanced CT (CECT) abdomen, which revealed an isolated duodenal duplication cyst in the second part of the duodenum on the mesenteric border. The lumen did not connect with the duodenum [Figure 1]. It appears to be embedded in the head of pancreas. Texture and size of the pancreas were normal. Conservative management was tried, keeping the patient nil orally supported by intravenous fluids, electrolytes, and analgesics. The symptoms improved in 2 days. Since then the patient is maintaining well.
|Figure 1: Computed tomography scan is showing the isolated duodenal duplication cyst|
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| Discussion|| |
Duplication of the alimentary tract is a term suggested by gross to encompass enterocystomas, enterogenous cysts, enteric cysts, giant diverticula, ileum duplex, and thoracic cysts of enteric origin.  The first case of duodenal duplication was reported by Sanger in 1880: A stillborn female found to have a duodenal duplication, a choledochol and three ileal duplications.  Waugh in 1923 performed the first operation on a 19-day-old girl presenting with vomiting and a palpable mass; a duplication of the second portion of duodenum was aspirated and packed; a gastroenterostomy was made at a subsequent operation but the patient died.  In 1927, Sohn was successful in resecting a duodenal duplication in an 8-year-old child.  The best consistent theory for the development of intra-abdominal duplication was given by Bremer. Intestinal lumen is markedly reduced or occluded by the increased epithelial cells, during the 6 th week of development. Normally, epithelial cells secrete a fluid which results in the formation of vacuoles which coalesce to form a lumen. Formation of a duplication results from failure of these vacuoles to coalesce into a single channel. The duplication may share a single mesentery and a single basement membrane or form a discrete tubular structure with its own walls and mesentery. 
Duodenal duplications are usually discovered during infancy and childhood (mostly before 10 years of age) with equal incidences among males and females. It is uncommon in adults. They may be single or multiple and usually found along the first and second portions of the duodenum on its mesenteric side on the anterior wall; both submucosal and intermuscular sites have been described. The blood supply is usually associated with that of the duodenum so that surgical dissection of the duplication from the duodenum is often impossible. Communication with the main lumen is rare. Communication with the pancreaticobiliary ductal system has also been reported. ,
Usually they are cystic, tubular or spherical in shape, and 2-12 cm diameter size. They are lined by mucosa, usually similar to that of duodenum but ectopic gastric (15%), small intestinal and pancreatic mucosa have also been reported. Outer lining is one or more layer of smooth muscle. Peristaltic movements may be present. , Contents may be mucilaginous, mucoid or watery, and clear or reddish brown in color. It can be associated with other congenital anomalies such as double gall bladder, congenital dislocation of the hip, ventricular septal defect, patent ductus arteriosus, ilial and gastric duplications, and mediastinal and esophageal cysts. The most common symptoms are periumbilical pain, vomiting, and gastrointestinal bleeding. Ulceration followed by perforation or hemorrhage can occur, especially in cases of the ectopic gastric mucosa. Pressure effects include gastric outlet or intestinal obstruction, recurrent pancreatitis, cholangitis, and obstructive jaundice. Ultrasound and CT may confirm the cystic nature of duplication cyst. Ultrasound shows a hypoechoic mass with strong posterior wall echoes and good through transmission due to the clear fluid content or an echogenic mass due to hemorrhage and inspissated material within the duplication. If the typical inner echogenic mucosal and outer hypoechoic muscle layers are seen on ultrasound, the diagnosis of duplication can be established. , Duplication cysts can be recognized on CT as smoothly rounded, fluid-filled cysts or tubular structures with thin, slightly enhancing walls in or adjacent to the wall of the part of the alimentary tract.  Cystic wall calcifications may occur rarely. Endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography, percutaneous transhepatic cholangiopancreatography can be advised to explore biliary or pancreatic ducts involvement, if any. Intraoperative cholangiogram can be done to clarify ductal anatomy.
We found about 132 reported cases after literature search. In 2003, Kim et al. presented a case of completely isolated duodenal duplication cyst and mentioned it to be the only report describing computed tomographic findings of completely isolated enteric duplication cyst in the English-language literature.  We did not found any other report, since then, and, to the best of our knowledge, this is the second case of isolated duodenal duplication cyst diagnosed by CT.
The isolated cyst can be managed conservatively. Surgical management is required based on symptoms and complications (obstruction or bleeding). Treatment options include open or laparoscopic excision or enucleation.
| Conclusion|| |
- Duodenal duplication cyst should be kept in mind in case of isolated cystic swelling in the upper abdomen
- CECT abdomen is an important investigation for isolated duodenal duplication cyst.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Gross RE, Holcomb GW Jr, Farber S. Duplications of the alimentary tract. Pediatrics 1952;9:448-68.
Sanger NI, Klopp A. Anatomical knowledge of congenital belly cysts. Arch Gynaek 1880;16:415.
Waugh OS. Congenital cyst of the duodenum. Surg Gynecol Obstet 1923;37:785.
Sohn A. Enterocystoma of upper digestive tract. Dtsch Z Chir 1927;205:69.
Bremer JL. Diverticula and duplications of the intestinal tract. Arch Path 1944;38:132.
Riker WL. Pseudocyst of the pylorus and duodenum. Am J Surg 1951;81:464-6.
Polson RA, Isaac JE. Enterogenous cyst of the duodenum. Gastroenterology 1953;25:431-4.
Faegenburg D, Bosniak M. Duodenal anomalies in the adult. Am J Roentgenol Radium Ther Nucl Med 1962;88:642-57.
Leonard P, Goethals-Borin J. A case of duodenal duplication. Acta Gastroenterol Belg 1962;25:133-8.
Kangarloo H, Sample WF, Hansen G, Robinson JS, Sarti D. Ultrasonic evaluation of abdominal gastrointestinal tract duplication in children. Radiology 1979;131:191-4.
Teele RL, Henschke CI, Tapper D. The radiographic and ultrasonographic evaluation of enteric duplication cysts. Pediatr Radiol 1980;10:9-14.
Bissler JJ, Klein RL. Alimentary tract duplications in children: Case and literature review. Clin Pediatr (Phila) 1988;27:152-7.
Kim SK, Lim HK, Lee SJ, Park CK. Completely isolated enteric duplication cyst: Case report. Abdom Imaging 2003;28:12-4.