|Year : 2013 | Volume
| Issue : 3 | Page : 226-228
Enteric duplication cyst in an 8 year old child
Siddharth Pramod Dubhashi1, Rajat Dinesh Sindwani1, Sangram Jadhav1, Harsh Kumar2
1 Department of Surgery, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Pathology, Padmashree Dr. D.Y. Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Web Publication||28-Mar-2014|
Siddharth Pramod Dubhashi
A-2/103, Shivranjan Towers, Someshwarwadi, Pashan, Pune - 411 008, Maharashtra
Source of Support: None, Conflict of Interest: None
Enteric duplications are rare congenital anomalies that can occur along the entire length of the gastrointestinal system. Their most common location is the small intestine, mostly the terminal ileum. Almost 70% of the cases present within 1 st year of life. The common symptoms include abdominal pain, vomiting, distension and constipation. Ultrasound, computed tomography scan and magnetic resonance imaging are useful in diagnosing the lesion. Excision of the duplication cyst is the treatment of choice. This is a case report of an 8-year-old male child who presented with enteric duplication cyst, which was attached to the terminal ileum with no communication with the bowel lumen. The cyst was excised and the child made a satisfactory recovery.
Keywords: Duplication cyst, enteric duplication, ileum
|How to cite this article:|
Dubhashi SP, Sindwani RD, Jadhav S, Kumar H. Enteric duplication cyst in an 8 year old child. Arch Int Surg 2013;3:226-8
| Introduction|| |
Enteric duplications are rare congenital anomalies that can occur along the entire length of the gastrointestinal system. They are defined by their histological appearance, which mimics that of the native gastrointestinal tract possessing an inner mucosa-submucosa layer surrounded by an outer smooth-muscle layer.  The commonest location is the small intestine, usually the terminal ileum. The estimated incidence is 1:4500 newborns. , Duplications of ileum appear as non-communicating spherical cysts. They are mistaken for mesenteric cysts, but are recognised by mucosal lining.  The objective of this paper was to discuss the clinical presentation, investigations, diagnosis and treatment of an 8-year-old child that presented with a duplication cyst of the ileum.
| Case Report|| |
This is a case report of an 8-year-old male child who presented with recurrent colicy pain in the abdomen for 3 years and periodic episodes of bilious vomiting. There was no history of fever or any other major illness. On examination, there was a tense cystic mass in the right iliac fossa with tenderness on deep palpation. No other abnormal finding on examination.
Haematological and biochemical investigations were within the normal limits. Ultrasound of the abdomen showed a round 2.8 cm × 2.6 cm × 1.8 cm well defined anechoic cystic structure on the right periumbilical region, with thin septa within just beneath the subcutaneous tissue adjacent to the small bowel loops, suggestive of mesenteric cyst or enteric duplication cyst. Computed tomography (CT) scan of the abdomen showed a smooth, rounded, fluid-filled cystic lesion with thin slightly enhancing wall [Figure 1].
Patient had exploratory laparotomy. There was a 5 cm × 3 cm cyst, 10 cm proximal to ileo-ceacal junction with adhesions between the cyst and ileo-ceacal junction and anterior abdominal wall. The base of the cyst was attached to the terminal ileum, but was not communicating with the bowel lumen. The cyst was excised completely. The continuity of the underlying bowel was maintained and the seromuscular defect was closed [Figure 2] and [Figure 3].
The cyst contained clear serous fluid. Cut section of the cyst showed small bowel mucosal lining. Microscopically, the cyst was lined by low columnar to cuboidal atrophic mucosa with mild sub-epithelial round cell infiltration and a well-developed smooth muscle coat [Figure 4] and a histological diagnosis of intestinal duplication cyst was made.
| Discussion|| |
Reginald Fitz first used the word "duplication" in 1884, to describe the remnants of the omphalo-mesenteric duct.  The term "alimentary tract duplication" was coined by W.E. Ladd to describe those congenital malformations that are seen on the mesenteric side of the associated alimentary tract and share a common blood supply with the native bowel.  The duplication is explained as a defect in the recanalization of the intestinal lumen after the solid stage of the embryological development.  Other theories include-persisting embryological diverticula or "aborted Gemini," intrauterine vascular accident theory.  The lesions are classified as: (1) Classical, with the shared common wall and blood supply (2). Completely isolated from the bowel, which has an independent blood supply (3) Intermediate, with part of the duplication independent and part of its sharing a common wall with bowel.  The lesion seen in our case was of an intermediate type. The vascular classification to facilitate surgical management divides the enteric duplications into - Type I (parallel) with the duplication located on the border of one mesenteric leaf and the straight artery to the duplication is separated from the straight artery to the bowel, Type II (intramesenteric) with the duplication located between the two leaves of the mesentery and the straight arteries pass over both surfaces of the duplication to reach the adjacent bowel. 
Almost 70% of the enteric duplications that present with symptoms do so within the 1 st year of life and 85% by 2 years of age.  The common symptoms include abdominal pain, vomiting, distension and constipation. Small cystic duplications can act as a lead point for small bowel intussusception or result in localized volvulus. Larger duplications can cause compression of adjacent intestine and cause obstructive symptoms. A malignant change can occur within the intestinal duplication.  Ultrasound, CT scan and magnetic resonance imaging (MRI) are useful in diagnosing the lesion. Ultrasound shows the double wall or muscular rim sign with an echogenic inner margin corresponding to the mucosa surrounded by a hypoechoic rim of tissue representing the smooth muscle layer.  The lesion manifests as a smooth rounded, fluid filled cysts or tubular structure with thin slightly enhancing wall on CT scan. MRI scan shows intracystic fluid with heterogeneous signal density on T1-weighted image and homogenous high signal intensity on T2-weighted image.
Due to the possible complications such as bowel perforation, bleeding, obstruction and malignant change, intestinal duplications require surgical intervention. Excision of the duplication is the treatment of choice. Small cystic or short tubular duplication can be managed with segmental resection along with adjacent bowel. Long tubular duplications will require mucosal stripping through a series of multiple incisions.  In our case, the cyst had no communication with the bowel lumen and hence, bowel resection was not required.
| Conclusion|| |
Enteric duplication cysts are rare congenital anomalies that have a varied clinical presentation. Early diagnosis and treatment reduces the risk of complications. Resection of the duplication cyst is the treatment of choice.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]