Imaging Findings of Duodenal Duplication Cyst Complicated ... · CaseReport Imaging Findings of...
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Case Report Imaging Findings of Duodenal Duplication Cyst Complicated with Duodenal Intussusception and Biliary Dilatation Eduardo Torres Diez, 1 Raúl Pellón Dabén, 2 Juan Crespo Del Pozo, 2 and Francisco José González Sánchez 2 1 Department of Radiology, Central de Asturias University Hospital, Oviedo, Spain 2 Department of Radiology, Marqu´ es de Valdecilla University Hospital, Santander, Spain Correspondence should be addressed to Eduardo Torres Diez; [email protected] Received 25 October 2015; Accepted 27 January 2016 Academic Editor: Vincent Low Copyright © 2016 Eduardo Torres Diez et al. is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Duodenal duplication cyst is an extremely rare congenital anomaly usually diagnosed in childhood. However, it may remain asymptomatic for a long period. In adults it usually manifests with symptoms related to complications as pancreatitis, jaundice, or intussusception. We present the radiology findings of a patient with a duodenal intussusception secondary to a duplication cyst. e usefulness of the magnetic resonance (MR) in this case is highlighted. 1. Case Report A 33-year-old woman with a history of intermittent jaundice was referred to our radiology department. She had com- plained of recurrent abdominal pain for 5 years. At the age of 30 years she had been diagnosed of cholelitiasis by an ultrasound performed in another centre. Her liver function tests were abnormal with slight elevation of bilirubin. First an abdominal ultrasound was realized. It showed an intussusception involving the duodenum and proximal jejunum. An anechoic cystic lesion was observed inside the lesion (Figure 1). Besides, the biliary tree was dilated. e study was continued with computed tomography with contrast and obtainment in portal phase, and aſter a complementary magnetic resonance (MR) with axial and coronal T2 weighted single-shot turbo spin echo, MR Cho- langiopancreatography and contrast enhancement sequences were performed. Gadolinium ethoxybenzyl diethylenetri- amine pentaacetic acid was used for the dynamic study. We realized vascular acquisitions and a delayed hepatobiliary phase. e axial CT images and T2 weighted sequences confirmed that the distal duodenum with surrounding fat, vessels, and the pancreatic head were invaginated into the proximal jejunum. Inside the intussusception a cystic lesion was also visualized. e stomach was not distended (Figures 2 and 3). e MR Cholangiopancreatography depicted that the extrahepatic bile duct was slightly dilated and pulled leſtward towards the cyst mass. e contrast enhancement sequences corroborated the simple cystic nature of the cause of intussusception (Figure 4). In the hepatocytic acquisition phase the contrast filled the biliary tree and the bowel lumen, but not inside the cyst lumen (Figure 5). An open surgery was the treatment elected. A laparotomy was realized and a cystic lesion measuring 4 × 4 × 3 cm was removed. At histopathologic analysis the cyst presented definitive criteria of duplication cyst (Figure 6). e postoperative period was uneventful and ten days later the patient was discharged. 2. Discussion Duplication cyst is a rare congenital condition that forms dur- ing the embryonic period of alimentary tract development. Most cysts are 2 to 4 cm in size. ey occur frequently in the distal ileum. Conversely duodenal duplication cysts are very uncommon and represent only 2 to 12% of all digestive tract duplications [1, 2]. Most of the duodenal duplication cyst are located on the second or third part of duodenum and share muscle layers. ey are commonly cystic and usually Hindawi Publishing Corporation Case Reports in Radiology Volume 2016, Article ID 3069576, 3 pages http://dx.doi.org/10.1155/2016/3069576
Transcript of Imaging Findings of Duodenal Duplication Cyst Complicated ... · CaseReport Imaging Findings of...
Case ReportImaging Findings of Duodenal Duplication Cyst Complicatedwith Duodenal Intussusception and Biliary Dilatation
Eduardo Torres Diez,1 Raúl Pellón Dabén,2
Juan Crespo Del Pozo,2 and Francisco José González Sánchez2
1Department of Radiology, Central de Asturias University Hospital, Oviedo, Spain2Department of Radiology, Marques de Valdecilla University Hospital, Santander, Spain
Correspondence should be addressed to Eduardo Torres Diez; [email protected]
Received 25 October 2015; Accepted 27 January 2016
Academic Editor: Vincent Low
Copyright © 2016 Eduardo Torres Diez et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.
Duodenal duplication cyst is an extremely rare congenital anomaly usually diagnosed in childhood. However, it may remainasymptomatic for a long period. In adults it usually manifests with symptoms related to complications as pancreatitis, jaundice,or intussusception. We present the radiology findings of a patient with a duodenal intussusception secondary to a duplication cyst.The usefulness of the magnetic resonance (MR) in this case is highlighted.
1. Case Report
A 33-year-old woman with a history of intermittent jaundicewas referred to our radiology department. She had com-plained of recurrent abdominal pain for 5 years. At the ageof 30 years she had been diagnosed of cholelitiasis by anultrasound performed in another centre. Her liver functiontests were abnormal with slight elevation of bilirubin.
First an abdominal ultrasound was realized. It showedan intussusception involving the duodenum and proximaljejunum. An anechoic cystic lesion was observed inside thelesion (Figure 1). Besides, the biliary tree was dilated.
The study was continued with computed tomographywith contrast and obtainment in portal phase, and after acomplementary magnetic resonance (MR) with axial andcoronal T2 weighted single-shot turbo spin echo, MR Cho-langiopancreatography and contrast enhancement sequenceswere performed. Gadolinium ethoxybenzyl diethylenetri-amine pentaacetic acid was used for the dynamic study. Werealized vascular acquisitions and a delayed hepatobiliaryphase. The axial CT images and T2 weighted sequencesconfirmed that the distal duodenum with surrounding fat,vessels, and the pancreatic head were invaginated into theproximal jejunum. Inside the intussusception a cystic lesion
was also visualized. The stomach was not distended (Figures2 and 3). The MR Cholangiopancreatography depicted thatthe extrahepatic bile duct was slightly dilated and pulledleftward towards the cyst mass. The contrast enhancementsequences corroborated the simple cystic nature of the causeof intussusception (Figure 4). In the hepatocytic acquisitionphase the contrast filled the biliary tree and the bowel lumen,but not inside the cyst lumen (Figure 5). An open surgerywas the treatment elected. A laparotomy was realized anda cystic lesion measuring 4 × 4 × 3 cm was removed. Athistopathologic analysis the cyst presented definitive criteriaof duplication cyst (Figure 6). The postoperative period wasuneventful and ten days later the patient was discharged.
2. Discussion
Duplication cyst is a rare congenital condition that forms dur-ing the embryonic period of alimentary tract development.Most cysts are 2 to 4 cm in size. They occur frequently inthe distal ileum. Conversely duodenal duplication cysts arevery uncommon and represent only 2 to 12% of all digestivetract duplications [1, 2].Most of the duodenal duplication cystare located on the second or third part of duodenum andshare muscle layers. They are commonly cystic and usually
Hindawi Publishing CorporationCase Reports in RadiologyVolume 2016, Article ID 3069576, 3 pageshttp://dx.doi.org/10.1155/2016/3069576
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Figure 1: Abdominal ultrasound image depicts the typical image ofintussusception with a simple cyst inside.
Figure 2: Axial and coronal CT shows that the distal duodenumwith surrounding fat, vessels, and the pancreatic head were invagi-nated into the proximal jejunum (curve arrow). The common bileduct is dilated (single arrow).
Figure 3: Coronal T2 weighted single-shot turbo spin echo RMimage confirms the cyst (arrow) as the cause of intussusception andbiliary dilatation.
communicate with pancreatic or bile ducts.The presence of acommunication with duodenal lumen is not frequent [1, 2].
Duodenal duplication cysts are usually diagnosed in thechildhood. However they may remain asymptomatic untiladulthood. Clinical manifestations in adults of duodenalduplication cyst are usually nonspecific and may easily bemisinterpreted. Abdominal pain, nausea, and vomiting are
Figure 4: MR Cholangiopancreatography reveals that the commonbile duct (large arrow) and the main pancreatic duct (small arrow)are pulled down and leftward into the elongated duodenum.
Figure 5: Coronal multiplanar reformation Gd-EOB-DTPAenhanced T1 weighted 3D GRE image obtained 30 minutes afterinjection shows contrast material in bile duct and duodenal lumen.Not inside the cyst.
Figure 6: An image of the histological examination shows charac-teristic findings of a duplication cyst and a double muscle layer, withtheir mucosal and submucosal layers.
the most common symptoms. They can present with acomplication, pancreatitis and cholestasis being the mostfrequent. Intussusception, gastrointestinal bleeding, and cystinfection are also common [1]. Symptoms are usually of longduration even if the intussusception is present [3]. Imagingtechniques usually suggest the diagnosis, but it must beconfirmed at histopathologic analysis. The criteria requiredfor the definitive diagnosis are the presence of alimentarymucosal lining, a smooth muscle coat, and an intimateattachment to the native gastrointestinal tract [4].
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Intussusception in adults is rare and there is an under-lying disorder in 90% of cases [3]. A mass can lead to thetelescoping of one bowel segment over the adjacent. Duo-denojejunal intussusceptions are rarely encountered becauseof fixation of a large portion of the duodenum to theretroperitoneum [3, 5–7]. Duodenojejunal intussusceptionsare almost always triggered by a benign cause as lipoma,adenoma, or hamartoma. In our case an enteric duplicationcyst acts as the lead point. However, malignant causes havealso been described [3, 5, 6].
Imaging studies are essential for a preoperative diagnosis.An ultrasonography is usually the first imaging techniqueperformed.Theultrasounddepicts the pathognomonic bowelwithin the bowel of the intussusceptions and can show thecystic nature of the duplication cyst. The localization ofintussusception usually changes during examination. Besidesit may be possible to see peristalsis in the wall caused bythe muscular layer [8]. Seldom, duplication cyst may presentas an echogenic mass [9]. The CT and MRI can confirmthe presence of intussusception and with contrast enhancethe cystic nature of duplication cyst. They have a betterspatial resolution than ultrasound and detect the presence ofcomplications like pancreatitis, being very useful for preoper-ative planning. The MR Cholangiopancreatography providesadditional information through better resolution of biliarytree. The addition of the hepatocyte-specific contrast allowsthe visualization of contrast inside the cyst which narrowsthe differential diagnosis. Only choledochal cyst which isin communication with biliary tree can present contrastfilling. Nonetheless, it has not been described as a causeof intussusception. Other possible and more frequent cysticlesions in epigastric area like pseudocyst, mesenteric cyst, orpancreatic cystic tumours can be completely excluded.
A treatment is necessary when adults present withsymptomatic intussusception. Open surgical intervention isthe most common technique for duplication duodenal cyst.Complete excision is usually frequent.This is the treatment ofchoice in case of complicated cyst intussusception [2]. Othertreatment options include surgical marsupialisation, surgicalresection, pancreaticoduodenectomies, and endoscopic mar-supialisation [1].
Conflict of Interests
The authors Eduardo Torres Diez, Raul Pellon Daben, JuanCrespo Del Pozo, and Francisco Jose Gonzalez Sanchezdeclare that there is no conflict of interests regarding thepublication of this paper.
References
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[2] N. P. Morley, A. T. Pyrros, V. Yaghmai, F. H. Miller, and P.Nikolaidis, “Biliary dilatation and duodenal intussusceptionsecondary to enteric duplication cyst: MDCT diagnosis,” Emer-gency Radiology, vol. 16, no. 3, pp. 243–245, 2009.
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[5] F. Watanabe, H. Noda, J. Okamura, N. Toyama, and F. Konishi,“Acute pancreatitis secondary to duodenoduodenal intussus-ception in duodenal adenoma,” Case Reports in Gastroenterol-ogy, vol. 6, no. 1, pp. 143–149, 2012.
[6] S. J. Jeon, S. E. Yoon, Y.-H. Lee, K.-H. Yoon, E.-A. Kim, andS. K. Juhng, “Acute pancreatitis secondary to duodenojejunalintussusception in Peutz-Jegher syndrome,” Clinical Radiology,vol. 62, no. 1, pp. 88–91, 2007.
[7] J. Gardner-Thorpe, R. H. Hardwick, N. R. Carroll, P. Gibbs, N.V. Jamieson, and R. K. Praseedom, “Adult duodenal intussus-ception associated with congenital malrotation,”World Journalof Gastroenterology, vol. 13, no. 28, pp. 3892–3894, 2007.
[8] M. S. Keller, T. R. Weber, C. Sotelo-Avila, D. S. Brink, andA. Luisiri, “Duodenal duplication cysts: a rare cause of acutepancreatitis in children,” Surgery, vol. 130, no. 1, pp. 112–115,2001.
[9] T. R. S. Prasad and C. E. Tan, “Duodenal duplication cystcommunicating with an aberrant pancreatic duct,” PediatricSurgery International, vol. 21, no. 4, pp. 320–322, 2005.
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