Radiol Oncol 2005; 39(3): 181-4. case report Communicating saccular pyloroduodenal duplication. Case report Ivica Sjekavica1, Marko Batinica1, Mario Lušić1, Irena Senečič-Čala2, Božidar Oberman1, Ranka Štern-Padovan1 1 Clinical Institute for Diagnostic and Interventional Radiology, School of Medicine, University Hospital Center Zagreb – Rebro; 2 Clinical Department of Pediatrics, School of Medicine, University Hospital Center Zagreb – Rebro, Zagreb, Croatia Background. Duplication anomalies of pyloroduodenal region are not common. Intestinal duplications should be considered if additional specific development malformations are present. Case report. We report a case of the pyloroduodenal duplication in 22-month-old girl by whom intermit-tent nausea and vomiting were the first symptoms. US revealed an anechoic cystic lesion between the stom-ach and the left liver lobe. The upper gastrointestinal contrast study revealed stenosis in the pylorobulbar region, as a result of the extrinsic compression. The diagnosis of the alimentary tract duplication cyst com-pressing the atypically formed head of pancreas was highly suspected by the contrast enhanced multi slice computerized tomography (MSCT). The intraoperative contrast application detected a communication be-tween both, duplication and pyloric region. The patohistological examination confirmed a duplication cyst containing gastric and duodenal mucosa with no ectopic pancreatic tissue. Conclusions. The ultrasound examination, as the initial diagnostic procedure of intestinal duplication, usu-ally reveals a cystic anechoic lesion. Additional barium study, contrast enhanced CT or MRI scan are use-ful in diagnosis of alimentary tract duplications, providing supplementary information. Key words: pylorus-abnormalities; duodenum-abnormalities Introduction Isolated duplications of the alimentary tract are rare congenital malformations with a re-Received 12 September 2005 Accepted 20 September2005 Correspondence to: Marko Batinica, M.D., Clinical Institute for Diagnostic and Interventional Radiology, University Hospital Center Zagreb – Rebro, Kišpatićeva 12, 10000 Zagreb, Croatia; Phone: +385 1 2388 455; Fax: +385 1 2388 250; E-mail: marko.batinica@zg.htnet.hr ported incidence of 1:5000.1,2 Duplication anomalies of the pyloroduodenal region are not common as well. Intestinal duplications should be considered if additional specific development malformations are present. The aetiology of duplication cysts may be multi-factorial.3 The usual symptoms in patients with alimentary duplication cysts are gas-trointestinal obstruction, vomiting, diffuse abdominal pain and sometimes melena. 2,4 182 Sjekavica I et al / Pyloroduodenal duplication Figure 1. US if the upper abdomen. Anechoic oval structure between stomach and left liver lobe. Case report A 22-month-old girl with abdominal pain and recurrent vomiting was presented in the recent 15-month-period. Physical examination findings showed a small palpable mass in the left epigastrium. Early sonographic findings revealed an anechoic oval structure between the stomach and the left liver lobe suspected to be a duplication of the alimentary tract. There was no proof of any communication to intraperitoneal structures. No communica-tion with the gastrointestinal tract could be demonstrated as well (Figure 1). The radiological examination included the upper gastrointestinal contrast radiography which revealed stenosis in the pyloroduode-nal region, 4 cm in length. Stenosis was con-sidered as a sign of the extrinsic compression (Figure 2). The contrast enhanced multi slice comput-erized tomography (MSCT) was compatible with US findings and contrast radiography. It revealed a well-defined cystic fluid collection, 3.3 x 3.9 cm, located between the left liver lobe and pylorus, suggesting an enteric dupli-cation and extrinsic compression on the duo-denal region. A mesenteric cyst, however, could not be excluded. The head of pancreas was severely deformed due to the cyst formation. There were no signs of acute pancreati-tis (Figures 3,4). Radiol Oncol 2005; 39(3): 181-4. Figure 2. Upper gastrointestinal contrast radiography. Stenosis in pyloroduodenal region as sign of extrinsic compression. The explorative surgery revealed a spheri-cal duplication anterior to the pyloric region. The intraoperative contrast application through the cystic structure suggested a narrow communication between the duplication and alimentary tract. A partial resection was performed due to the common wall with py-lorus shared in small segment. Mucosa of the remnant cyst wall was excised. The histopa-tological examination of specimen confirmed a pyloroduodenal duplication cyst containing gastric and duodenal mucosa. Discussion Duplication cysts are spherical or elongated hollow structures, lined by epithelium which is usually identical to a part of the alimentary tract they are aligned to, usually sharing com-mon blood supply.1 Duplications occur due to a fault recanal-ization of the temporarily obliterated fetal in-testine or incomplete embryogenic budding. They tend to be associated with other congen-ital malformations, mostly vertebral anom-alies, intestinal atresia, double gallbladder or double uterus.2,5 A gastrointestinal duplica- Sjekavica I et al / Pyloroduodenal duplication 183 Figures 3, 4. Contrast enhanced MSCT of the upper abdomen. Well-defined cystic fluid collection, 3,3x3,9 cm, between left liver lobe and pylorus, suggesting an enteric duplication. tion may develop at any level of the gastroin-testinal tract, often containing ectopic tissue. Gastric mucosa and pancreatic tissue are the only ones that have clinical significance. The usual localization of duplication development is enteromesenteric side of the alimentary tract. The majority of duplications are diag-nosed in the early childhood due to symptoms developing in the first years of life.3,6-7 Differential diagnoses of duplications in children include cystic neoplasm, congenital and parasitic cysts and pancreatic pseudocyst. Symptoms of intestinal duplications in children are mostly non-specific, depending on the localization. They may present as vom-iting, palpable abdominal mass, problems with feeding and pancreatitis. Lesions in dis-tal segments of intestine include flank abdominal pain, palpable tumour and melena.3 As a method of treatment, surgery should be attempted to remove the duplication radi-cally, even if together with adjacent gut segment. If the cyst is closely related to vital structures, a total excision may not be possi-ble. In such cases, the partial excision remains as a possible solution. The diagnosis of a duplication cyst may be suspected on barium enhanced radiographs demonstrating the extrinsic pressure pro-duced by abdominal mass.8 US, CT and MR confirm a definitive diagnosis. On US, duplications appear as anechoic mass with a thin echogenic rim representing mucosa, covered by a hypoechoic muscular wall. These findings are characteristic for the non-communicating type of a duplication cyst.7,9 CT demonstrates the location and extension of the duplication defining adjacent structures and excluding additional abnor-malities. Rarely, CT demonstrates cyst wall calcifications.7,10 MR cholangiography is helpful in detect-ing biliary and ductal anomalies.11,12 In addition, radionuclide imaging with 99mTc can show the increased uptake if a cyst contains gastric mucosa.7 Conclusions Duodenal duplications constitute about 5% of all alimentary tract duplications. Pato-histological findings in duplications usually show ectopic tissue such as gastric and/or pancreatic mucosa.3 Complications as bleed-ing, perforation of ulceration may occur. A malignant alteration of duplication is ex-tremely rare.13 In our case, the diagnosis of the alimentary tract saccular duplication compressing the atypically formed head of pancreas was high-ly suspected by US and contrast enhanced CT. Radiol Oncol 2005; 39(3): 181-4. 184 Sjekavica I et al / Pyloroduodenal duplication A contrast study of duplication during the surgical excision detected a communication between the duplication and pyloric region. The patohistological examination confirmed a duplication cyst containing gastric and duo-denal mucosa. The ultrasound examination, as an initial diagnostic procedure of the intestinal dupli-cation, usually reveals a cystic anechoic lesion. 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