An adult case of a retroperitoneal isolated enteric duplication cyst with the imaging changes over time

Background Adult cases of retroperitoneal isolated enteric duplication cyst (IEDC) are rare, with only 17 case reports in the relevant literature. We herein present a case, which was characterized by changes in intra-cystic density on computed tomography (CT), which was safely resected by laparoscopic surgery. Case presentation The patient was a 60-year-old male who received abdominal CT to investigate the cause of increased serum CA19-9 levels. CT revealed a unilocular cystic mass located in the lower right retroperitoneum. The size increased from 5 to 10 cm in three and a half years and the CT value decreased from 101 Hounsfield Units (HU) to 20 HU. We performed laparoscopic surgical resection, because the possibility that the enlargement of the lesion represented malignant transformation could not be denied. The large cystic mass firmly adhered to the appendix and its mesentery via the retroperitoneum, the appendix was resected en bloc with the cystic lesion. Microscopically, it had no communication with the appendix, and had an intestinal wall structure of muscularis mucosae and muscularis propria. The final pathological diagnosis was IEDC in the retroperitoneal space. There was no histological evidence of malignancy. Conclusion When we encounter a retroperitoneal cystic lesion, we should consider the possibility of malignancy to determine the treatment strategy and perform a careful operation without breaking the cyst wall, irrespective of the preoperative diagnosis.

1078 Enteric Duplication Cyst in An Adult: Presenting with Diarrhea and Vomiting

Intestinal duplication cysts are rare disease entirety, most commonly presenting in childhood. The incidence is 1:4,500 births, with a slight male predominance. They can occur anywhere along the alimentary tract, 35% occur in the ileum and 10% in jejunum. Diagnosis can prove challenging as they can present with a vast variation of symptoms and mimic other pathologies. A 29-year-old male presented to A&E following a collapse. He had been suffering of diarrhoea and vomiting with lower abdominal discomfort. The patient was otherwise fit and well and no surgical history. On physical examination his abdomen was generally tender with no peritonism but was tachycardic, tachypneic but normotensive. His blood pressure dropped to 70/56, heart rate 130 and temperature increased to 41.2 degrees. A CT abdomen and pelvis with contrast was subsequently performed while on intensive care. There was a huge fluid-filled structure almost filling the entire pelvis and right side of the abdomen measuring up to 18cm in transverse diameter and 38cm longitudinally. The fluid filled structure appeared to communicate with a loop of small bowel in the right iliac fossa. There was no sign of obstruction. Due to the CT findings and the patient’s clinical status a laparotomy was performed. A large congenital duplication cyst was seen which was adherent to 40cm of the small bowel. The section of bowel was 130cm distal to the DJ flexure. The small bowel including the cyst was resected and hand sewn end-to-end anastomosis performed.

Ileal duplication cyst with giant polypoidal gastric heterotropia:

Enteric duplication cysts (EDCs) are congenital malformations of the gastrointestinal tract. EDCs can present as tubular or spherical cystic lesions of the abdomen. The tubular variant of EDC arises as an outpouching from the bowel wall, whereas the spherical variant rarely shows bowel communication. EDCs are known to harbour heterotopic pancreatic parenchyma or gastric mucosa. We present a case of EDC of the ileum (tubular type) with heterotopic gastric mucosa in a 7-year-old child who came with malena and abdominal discomfort. CT revealed focal abnormal dilatation of the ileal loop with polypoidal mucosal thickening. Differential diagnosis of lymphoma, bowel polyps and Meckel’s diverticula with gastric heterotopia (GH) were considered. Subsequent surgery followed by histopathology revealed it to be EDC with GH. We discuss this case to familiarise radiologists with the atypical imaging features of EDC, to prevent misdiagnosis and initiate prompt treatment in appropriate clinical settings.

Giant Gastroduodenal Duplication Cyst with Juxta-Pancreatic Communication

Enteric duplication cysts are rare congenital malformations with a low incidence and there are only a few reports in the literature. Their clinical presentation varies according to the location and the type of duplication. Their overall prognosis is good if early surgical intervention is provided. We present a case of a giant gastroduodenal duplication cyst with a juxta-pancreatic communication in a 2-month-old boy who was successfully treated surgically. It is imperative to be aware of this rare congenital malformation that can present clinically with a wide range of non-specific symptoms that can cause significant morbidity and mortality if the treatment is delayed. Keywords: Pancreatic Duct, Congenital Abnormalities, Intestinal Diseases, Newborn.

Pediatric Gastrointestinal Radiology

Chapter 12 examines radiologic images for common and uncommon pediatric gastrointestinal disorders. These include neonatal high bowel obstructions such as midgut malrotation and volvulus, duodenal atresia, duodenal web, annular pancreas, and pyloric stenosis. The chapter goes on to look at neonatal low bowel obstruction, including ileal disease such as ileal atresia and meconium ileus and colonic disease such as Hirschsprung disease and meconium plug. We then look at causes of pediatric bowel obstruction in older patients, such as intussusception, appendicitis, enteric duplication cysts, and inguinal hernia. Additional neonatal disorders discussed include necrotizing enterocolitis, and meconium peritonitis. Diseases of the pancreas examined include cystic fibrosis and pancreatitis. Liver tumors reviewed are infantile hepatic hemangioma and hepatoblastoma. Diseases of the biliary system looked at include choledochal cysts and biliary cysts, and biliary atresia. Splenic abnormalities examined include polysplenia and asplenia, heterotaxy syndromes, and sickle cell disease.

Transient Insulin Resistance in Propionic Acidaemias

Propionic acidaemia (PPA) is a disorder of amino acid and odd-chain fatty acid metabolism. Hypoglycemia is a commonly described finding rather than hyperglycemia during metabolic decompansation of PPA. We describe 9 months old boy with PPA, who was admitted with metabolic decompansation, persistent hyperglycemia and transient insulin resistance. Hyperglycemia did not respond to high insulin infusion. Plasma glucose only improved when glucose infusion rate (GIR) reached 7 mg/kg/min. The literature review showed high mortality rate in patients with organic acidaemias, with severe insulin-resistant hyperglycaemia. An important challenge is the balance between enough GIR to achieve targeted insulin level beyond which risks of hyperglycemia start to outweigh potential anabolic benefits of additional insulin secretion. Given the few case reports published, timely clinical attention should be made to achieve adequate caloric delivery through alternative sources other than high GIR to permit for better glycemic control, especially when insulin-resistant hyperglycemia is present. Keywords: Pancreatic Duct; Congenital Malformation; Surgery; Enteric Duplication; Newborn

Asymptomatic Enteric Duplication Cyst in a Geriatric Cat: Case Report and Review of the Literature

ABSTRACT An 11 yr old female neutered domestic shorthair presented for an 8 mo history of an asymptomatic abdominal mass. Computed tomography described an irregular, cystic structure closely associated with the duodenum, and focal ultrasonography confirmed the mass shared outer layers with the intestinal wall. Coeliotomy revealed the mass was originating from, and firmly adhered to, the antimesenteric border of the duodenum but was not communicating with the intestinal lumen. En bloc mass resection with omentalization was performed without small intestinal resection. Histopathology confirmed an enteric duplication cyst. The cat made a full recovery and remained asymptomatic postoperatively with no evidence of recurrence. A review of the literature confirms the duodenum to be the most common location of enteric duplication cysts in felines and that subtotal excision is curative in most cases. This differential should be considered in cases of cystic gastrointestinal structures in juvenile and adult felines, with or without associated clinical signs. In cases of luminal involvement or malignant transformation, intestinal resection and anastomosis is more appropriate. This report describes the presentation, investigations, and treatment of an asymptomatic duodenal duplication cyst in an adult feline and summarizes and compares current knowledge of the condition between veterinary and human literature.