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Gastrointestinal duplication isa rare congenital anomalythat usually presents within

the first few years of life. There is a va-riety of clinical manifestations, de-pending on the location within thegastrointestinal tract. We describe thecase of a 19-year-old man who had nosignificant medical history but pre-sented with acute symptoms of gastricoutlet obstruction. He was discoveredto have a large, noncommunicatingduplication cyst with gastric mucosain the antrum of the stomach.

CASE REPORT

A 19-year-old man presented with

a 7-day history of worsening epigas-tric pain, nausea and vomiting 1 to 3hours after eating. He had no historyof nausea, vomiting, pain, fever, jaun-dice, change in bowel habit, abdomi-nal surgery or other significant med-ical conditions. Physically, he was thinbut well developed. He complained ofmoderate epigastric tenderness. Afreely mobile upper abdominal masswas noted. Laboratory evaluation wasunremarkable with respect to theblood count, serum amylase level,liver function and urinalysis.Chest and abdominal plain films

were unremarkable. Computed to-mography (Fig. 1) with contrast showeda cyst mass measuring 7 × 7 cm. The

mass was thought to be located in theduodenum, as demonstrated by con-trast surrounding but not within thecystic mass. There was also a centralpneumobilia, most likely a result of themass stretching the ampulla of Vater.

Case ReportÉtude de cas

DUPLICATION CYST OF THE ANTRUM: A CASE REPORT

Shailesh Gupta, BS; Danny Sleeman, MD; Basel Alsumait, MD; Lisa Abrams, MD

From the Department of Surgery, University of Miami School of Medicine, Miami, Fla.

Accepted for publication Dec. 4, 1997

Correspondence to: Dr. Danny Sleeman, Division of Trauma Services, Department of Surgery (D-40), PO Box 016960, Miami FL 33101, USA; tel. 305 585-5280; fax 305324-7384

© 1998 Canadian Medical Association (text and résumé)

Gastrointestinal duplication is a rare congenital anomaly. Although it usually presents within the first fewyears of life, it may appear much later as described in this report of a 19-year-old man who had symptomsof gastric outlet obstruction. He was found to have a noncommunicating antral duplication cyst. The cystwas managed by antrectomy with excision of the cyst and several centimetres of duodenum. Microscopi-cally the duplication cyst contained a mucosa, submucosa and muscularis. There was no evidence of ulcera-tion or malignant cells. His recovery was smooth. The etiology, presentation and management of antralduplication cysts causing gastric outlet obstruction are discusssed.

La duplication gastro-intestinale est une anomalie congénitale rare. Même si elle se manifeste habituelle-ment au cours des premières années de la vie, elle peut faire son apparition plus tard, comme on le décritdans ce compte rendu sur un homme âgé de 19 ans qui présentait des symptômes de sténose du défilé gas-trique. On a découvert qu’il avait un kyste de duplication antrale non communicante. On a traité le prob-lème en procédant à une antrectomie et à une excision du kyste et de plusieurs centimètres de duodénum.L’examen microscopique a révélé que le kyste de duplication contenait une muqueuse, une sous-muqueuseet une couche musculeuse. Il n’y avait aucun signe d’ulcération ou de présence de cellules malignes. Le pa-tient s’est rétabli sans problème. Les auteurs discutent de l’étiologie, de la présentation et du traitement dekystes de duplication antrale causant une sténose du défilé gastrique.

FIG. 1. Computed tomography scan showing cys-tic lesion.

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The mass was believed to be either aduodenal duplication cyst or a chole-dochal cyst.Based on the patient’s symptoms of

gastric outlet obstruction and CTfindings, we carried out an exploratorylaparotomy the next day. A cystic massmeasuring 9 cm was noted in theantrum of the stomach along thegreater curvature (Fig. 2). Because ofthe size of the cyst, an antrectomy wasperformed along with excision of theantral duplication cyst and the first fewcentimetres of the duodenum. Recon-stuction was carried out using the Bil-roth I technique. No other cysts orabnormalities were found. Postopera-tively, the patient had an uncompli-cated recovery.Gross examination of the operative

specimen (Fig. 3) showed at 9-cmnoncommunicating cystic, distalantral mass along the greater curva-ture of the stomach. The cyst draineda collection of clear, mucinous fluid.Microscopic study demonstrated amucosa, submucosa and muscularis.The mucosa was a variant of the gas-

tric type with mucous pyloric-typeglands. There were no signs of ulcera-tion or malignancy.

DISCUSSION

Enteric duplication is a particularlyrare congenital entity in adults; themajority of cases occur in children.1 Bydefinition, a gastrointestinal duplica-tion must have a layer of smooth mus-cle, be located within or adjacent topart of the gastrointestinal tract andhave a mucous membrane lining simi-lar but not adjacent to the segment ofthe gastrointestinal tract.2 A number oftheories have been propounded to ex-plain the embryonic development ofgastrointestinal duplications. These in-clude abortive twinning,3 persistentembryologic diverticula that later de-velop into duplications,4 splitting ofthe notochord,5 aberrant recanaliza-tion of the lumen6 and hypoxic or trau-matic events early in fetal develope-ment.7 No single theory adequatelyexplains all types of duplications.Duplications can be found any-

where in the alimentary tract frommouth to anus.8 They tend to be morecommon in females and are some-times associated with other develop-mental abnormalities, including a sec-ond duplication elsewhere in thegastrointestinal tract. Although theileum is the most common site,9 in-volvement of the stomach is the mostuncommon, occurring in approxi-mately 4% of all enteric duplications.10

In a composite review of 281 gas-trointestinal duplications reported in4 separate, comprehensive studies,only 21 (7.5%) were located in thestomach. Of those 21, only 1 was re-ported in the pylorus or distalantrum.11 The majority of stomachduplications are on the greater curva-ture,12,13 and are noncommunicatingand cystic in nature. Although entericduplications may contain any type of

gastrointestinal mucosa, only gastricmucosa and ectopic pancreatic tissueare clinically significant: they may pre-sent with signs of ulceration and pan-creatitis.11 In addition, rare cases ofmalignant disease within the cyst havebeen reported.14

According to Hawkins, Loweryand Mullen2 there are 4 common pre-sentations of gastric duplications: painfrom distension of the cyst, intestinalobstruction, intestinal necrosis frompressure on mesenteric vessels, and ul-ceration and hemorrhage.2 The mostcommon physical finding is a palpablemass.15 The diagnosis is suggested bythe medical history, a palpable ab-dominal mass and radiologic detec-tion of an epigastric mass. Althoughplain films and barium studies mayyield the diagnosis, magnetic reso-nance imaging and CT are needed toassess the nature and size of the mass.The most conclusive evidence, how-ever, is ultrasonographic demonstra-tion of the cyst with a hypoechoicmuscle layer and an inner echogenicmucosal layer.11

Therapy for the duplication is sur-gical. Resection of the entire duplica-tion with a rim of normal stomach isadvised. Reconstruction can be per-formed using Bilroth I and II proce-dures. This therapy is in contrast tothe treatment of duodenal duplica-tion, in which resection can jeopardizethe ampulla of Vater, common bileduct or pancreatic duct. Most cysticduplications of the duodenum aretreated by surgically creating a win-dow between the duodenal lumen andthe duplication cyst.

References

1. Alberti-Flor JJ. Endoscopic appearance ofadult gastric duplication cyst [letter]. AmJ Gastroenterol 1994;89(10):1919-20.

2. Hawkins ML, Lowery CH, Mullen JT.

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FIG. 3. Operative specimen.

FIG. 2. Gastric duplication.

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Gastric duplication. South Med J 1974;67:189-90.

3. Lewis PL, Holder T, Feldman M. Du-plication of the stomach: report of acase and review of English literature.Arch Surg 1961;82:634-40.

4. Lewis FT, Thyng FW. Regular occur-rence of intestinal diverticula in em-bryos of pig, rabbit, and man. Am JAnat 1908;7:505-19.

5. Bentley JFR, Smith JR. Developmen-tal posterior enteric remnants andspinal malformations. Arch Dis Child1960;35:76-86.

6. Bremer JL. Diverticula and duplica-tions of the intestinal tract. Arch Pathol1944;38:132-40.

7. Bishop HC, Koop CE. Surgical man-

agement of duplications of the alimen-tary tract. Am J Surg 1964;107:434-42.

8. Holcomb GW 3d, Gheissari A, O’NeillJA Jr, Shorter NA, Bishop HC. Surgicalmanagement of alimentary tract duplica-tions. Ann Surg 1989;209(2):167-74.

9. Ildstad ST, Tollerud DJ, Weiss RG,Ryan DP, McGowan MA, Martin LW.Duplications of the alimentary tract.Clinical characteristics, preferred treat-ment, and associated malformations.Ann Surg 1988;208(2):184-9.

10. Luks FI, Shah MN, Bulauitan MC, Lo-Presti PA, Pizzi WF. Adult foregut du-plication. Surgery 1990;108(1):101-4.

11. Macpherson RI. Gastrointestinal tractduplication: clinical, pathologic, etio-logic, and radiologic considerations.Radiographics 1993;13(1):1063-80.

12. Chawla A, Gadaleta D, Kenigsver K,Kahn E, Markowitz J. Erosion throughthe posterior gastric wall by a pancreaticpseudocyst secondary to gastric duplica-tion. J Pediatr Gastroenterol Nutr1991;13:115-8.

13. Koltun WA. Gastric duplication cyst.Endoscopic presentation as an ulcer-ated antral mass. Am Surg 1991; 57(7):468-73.

14. Coit DG, Mies C. Adenocarcinoma aris-ing within a gastric duplication cyst [re-view]. J Surg Oncol 1992;50(4):274-7.

15. Wieczorek RL, Seidman I, Ranson JH,Ruoff M. Congenital duplication ofthe stomach: case report and review ofthe English literature. Am J Gastroen-terol 1984;79(8):597-602.

GUPTA ET AL

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ENTEROCLYSIS — ADHESION CAUSINGPARTIAL SMALL-BOWEL OBSTRUCTION

The answer to question “a” is entero-clysis, a double-contrast study of thesmall bowel following intubation ofthe duodenum. The diagnosis (ques-tion “b”) is adhesion (see Figure, ar-row) causing partial obstruction.In several centres, enteroclysis is now

the primary radiologic technique usedto investigate the small bowel. Acceptedclinical indications for small-bowel radi-ography include the following: unex-plained gastrointestinal bleeding, possi-ble small-bowel tumour, small-bowelobstruction, Crohn’s disease and mal-absorption.

The current literature reflects thelimitations of the conventional small-bowel follow-through and the impor-tant contribution of enteroclysis in thework-up and subsequent managementof patients with possible small-boweldisease.

Reference

1. Maglinte DDT, Kelvin FM, O’ConnorK, Lappas JC, Chernish SM. Currentstatus of small bowel radiography [re-view]. Abdom Imaging 1996;21(3):247-57.

© 1998 Canadian Medical Association

Radiology for the SurgeonChirurgie et radiologie

CASE 21. DIAGNOSIS

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