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I M A G E S OPEN ACCESS

Duodenal Duplication Cyst having Ectopic Gastric and Pancreatic Tissues

Binod Kumar Rai,* Samina Zaman1, Bilal Mirza, Ghazala Hanif

1, Afzal Sheikh

A 1-year-old female child presented with distention of

abdomen, accompanied with occasional episodes of

vomiting and abdominal pain for the past eight

months with no history of constipation or fever. The

child was vitally stable. On inspection upper abdomen

was found distended and mild tenderness in epigas-

trium on deep palpation. Laboratory investigations

were within normal limits. The plain radiograph of ab-

domen was unremarkable. Ultrasound scan showed a

6.9 cm x 7.5 cm sized cystic area with internal debris

at porta hepatis, compressing the liver. CT scan

showed a 5 cm x 7 cm sized cyst extending from

porta hepatis to the duodenum (Fig. 1). The preopera-

tive differentials were duodenal duplication and

choledochal cyst.

Figure 1: CT scan showing a hypo-dense area at porta hepatis.

At operation, a cyst medial to the gall bladder, push-

ing the stomach and the pancreas anteriorly and inti-

mately related to the second part of the duodenumwas found (Fig. 2).The content of the cyst was clear

mucous on aspiration. Intra-operative cystogram was

performed that ruled out its communication with biliary

and alimentary tracts (Fig. 3). The wall of the cyst was

opened and stripping of mucosal lining performed

after excising resectable portion of the cyst. The cyst

was sharing common wall with duodenum and was

non - communicating. The child made an uneventful

recovery and was discharged on the fifth postopera-

tive day. Histopathology of the specimen showed gas-

tric mucosal lined tissue having smooth muscles in

the wall along with ectopic pancreatic tissue (Fig.

4,5).

Figure 2: Dissection of the duodenal duplication cyst (Arrow).

Figure 3: Intra-operative cystogram showing no communication

with pancreatico-biliary ducts and duodenum.

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Figure 4: Microphotograph showing gastric mucosa with underlying

muscle layer (x200).

Figure 5: Microphotograph showing pancreatic tissue (x400).

DISCUSSION

Gastrointestinal duplications may be cystic or tubular

in shape with an intimate contact with the adjacent

gut, smooth muscles in their wall, and mucosa re-

sembling that of gastrointestinal tract. Duplications

can present along any part of gastrointestinal tract,

commonly along the ileum; duodenal duplications

account for 5% of all gastrointestinal duplications. In

15-25% of cases ectopic gastric mucosa may be

found. Few cases of duodenal duplications containing

ectopic pancreatic tissue have been reported in litera-

ture. Concurrence of ectopic gastric and pancreatictissues in a duodenal duplication cyst, as found in the

index case, is however extremely rare [1-3].

Duodenal duplications may occur along the first and

second parts of duodenum and are cystic with no

communication with the intestinal lumen in most of

the cases. Rarely, they can arise from pancreatico-

biliary ducts. These cysts may be confused with

choledochal cysts on account of their location be-

tween porta hepatis and duodenum. The presentation

could be with abdominal pain, palpable epigastric

mass, relapsing pancreatitis, and vomiting. In case of

ectopic gastric mucosa, there could be intra-cystic

hemorrhage or perforation of the cyst with peritonitis

[2,3].

Ultrasound scan, upper gastrointestinal contrast

study, CT scan, magnetic resonance cholangio

pancreatography (MRCP), and endoscopy are im-

portant tools for preoperative diagnosis. Surgical re-

section is the treatment of choice for alimentary tract

duplications. However, in case of duodenal duplica-

tions, excision of as much as part of duplication and

mucosal stripping of the rest is preferred on account

of its close proximity with pancreatico-biliary ductal

systems. We proceeded on the same lines in our pa-

tient. Intra-operatic cystogram is mandatory to rule

out its communication with pancreatico-biliary tree.

Similarly, we have ruled out the communication of the

cyst with pancreatico-biliary system and gut lumen by

performing intra-operative cystogram. Drainage of the

duplication cysts into the duodenum or into a Roux

limb of jejunum is also an acceptable alternative [1-4].

REFERENCES

1. Lund DP. Alimentary tract duplications. In: ONeill JA, RoweMI, Grosfeld JL, Fonkalsrud WE, Coran AG. Editors. Pediat-ric Surgery, 6th ed, Philadelphia: Mosby, 2006:1389-99.

2. Narlawar RS, Rao JR, Karmarkar SJ, Gupta A, Hira P.Sonographic findings in a duodenal duplication cyst. J ClinUltrasound 2002; 30:566-8.

3. Lavine JE, Harrison M, Heyman MB. Gastrointestinal dupli-cations causing relapsing pancreatitis in children.Gastroenterol 1989; 97:1556-8.

4. Irani S, Kozarek R, Mason V. Duodenal Duplication Cysts: Arare, but treatable cause of relapsing pancreatitis. Am JGastroenterol 2009;104:S60-1.

AFFILIATION:Department of Paediatric Surgery and Department of Histopathology

1

The Childrens Hospital and the Institute of Child Health Lahore,

Pakistan.

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Rai et al, Duodenal duplication cyst

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CORRESPONDENCE:* Dr. Binod K Rai, Department of Pediatric Surgery,

The Childrens Hospital and the Institute of Child Health Lahore,

Pakistan.

Email:* binod_50@hotmail.com

Received on: 25-02-2012 Accepted on: 20-03-2012

http://www.apspjcaserep.com 2012 Rai et al,

This work is licensed under a CreativeCommonsAttribution3.0UnportedLi-cense

Competing Interests: None declared Source of Support: Nil

How to cite

Rai BK, Zaman S, Mirza B, Hanif G, Sheikh A. Duodenal duplication cyst having ectopic gastric and pancreatic tissues. APSP J Case Rep

2012: 3: 15.

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