Duodenal duplication cysts are benign rare congenital anomalies reported mainly in the pediatric population, but seldom in adults. Symptoms depend on the type and location and can present as abdominal pain, distension, dysphagia or dyspepsia. They have been reported to be responsible for duodenal obstruction, pancreatitis and, in rare cases, gastrointestinal bleeding. We present a case of a duodenal duplication cyst in a 43-year-old man presenting as melena. Initial gastroduodenoscopy and colonoscopy did not reveal any bleeding focus. However, the patient began passing melena after 3 d, with an acute decrease in hemoglobin levels. Subsequent studies revealed a duplication cyst in the second portion of the duodenum which was surgically resected. Histology revealed a duodenal duplication cyst consisting of intestinal mucosa. There was no further bleeding and the patient recovered completely. In rare cases, duodenal duplication cysts might cause gastrointestinal bleeding and should be included in the differential diagnosis.
Gastrointestinal hemorrhage; Duodenum; Duplication
Duplications of the alimentary tract are very rare. A one-month-old female presented with symptoms of anorexia, vomiting and continuous watery diarrhea. The plain abdominal radiograph showed thickened intestinal wall and signs of small bowel obstruction. The fevers, vomiting, and continuous wartery diarrhea persisted despite antibiotics, and worsened. The patient failed to respond to medical managements, 27 hours after admission, the patient died due to multiple organ failures. The autopsy was performed, small bowel obstruction due to an ileocecal duplication cyst (3 × 3 cm) was recognized. The ileocecal duplication cyst was attached to the ileum which was changed edematous and necrotic. This potential diagnosis should be borne in mind for a patient who complains of abdominal symptoms with an unknown cause, and duplication cyst should be recognized as a fatal cause in infant.
sudden unexpected death; small bowel obstruction; ileocecal duplication cyst
This is an analysis of 6 patients with enteric duplications seen over an 8 year period at the Department of Pediatric Surgery, Dongsan Medical Center. They were all males but one. All duplications were cystic, and single except one. Locations of duplications were in the duodenum in one patient, in the jejunum in one, and in the terminal ileum in four. Five of the 6 patients were seen within 1 year of life. Three were newborn infants who had symptoms of intestinal obstruction with palpable mass since birth. Duplication cyst acted as a leading point of intussusception in 4 month and 8 month old infants respectively. One jejunal duplication was found in an 11-year-old boy who had malrotation of the midgut with Ladd's bands. Clinical presentation, embryogenesis of duplication, and management are discussed.
In a 20-year period at the Los Angeles Children's Hospital, 46 infants and children have had operation for cysts within the abdomen. The age range of patients was from newborn to 13 years. Most of them were under four years old. There were four general groups of these cysts. (1) About one-half were cysts of the ovary, some of them serous and some dermoid. These cysts are attached by a stalk that often twists, causing gangrene or rupture with acute symptoms simulating appendicitis. (2) Next in frequency were cysts arising in the mesentery of the intestine. They usually caused little trouble until by their size (up to a 2-quart capacity) they created pressure and obstruction in the intestine. (3) Enteric cysts were found in four patients. (4) Cysts of the pancreas were present in three of the children.
X-ray examination was helpful in diagnosis. Usually the type of cyst was not determined until operation was done. Transection of the intestinal tract sometimes was necessary for removal of the cyst. Surgical correction was satisfactory in 44 of the 46 cases.
Midgut malrotation is a congenital anomaly presenting mainly in the childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually recognized intra-operatively, therefore a high index of suspicion is always required when dealing with any case of acute intestinal obstruction.
PRESENTATION OF CASE
We report two cases of young adults who presented with symptoms of acute intestinal obstruction and were diagnosed intra-operatively as cecal volvulus and paraduodenal hernia, respectively, caused by midgut malrotation. Post-operative CT scan confirmed these findings.
Malrotation of the intestinal tract is a product of an aberrant embryology. The presentation of intestinal malrotation in adults is rare (0.2–0.5%). Contrast enhanced CT can show the abnormal anatomic location of a right sided small bowel, a left-sided colon and an abnormal relationship of the superior mesenteric vein (SMV) situated to the left of the superior mesenteric artery (SMA) instead of to the right.
Anomalies like midgut malrotation can present as an operative surprise and awareness regarding these anomalies can help surgeons deal with these conditions.
Midgut malrotation; Acute intestinal obstruction; Cecal volvulus; Paraduodenal hernia
Lipoma within jejunal duplication presenting as abdominal bloating and partial intestinal obstruction is an exceptional clinical entity. We report a case of 68-year-old man complaining of abdominal bloating for 10 d due to multiple lipomas arising from jejunal duplication cysts. Only a few cases of a single lipoma within a Meckel’s diverticulum giving rise to this clinical scenario have been reported in the English language literature. However, no case of multiple lipomas within jejunal duplication cysts has been reported. We present a case in which double-balloon endoscopy revealed a small intestinal structure changed into Meckel’s diverticulum-like cavities containing several lipomas. This case highlights intestinal lipoma as an uncommon cause of adult intussusceptions, which should be included in the differential diagnosis of small intestinal obstruction and appropriate examinations should be chosen.
Duplication cyst; Lipoma; Double-balloon endoscopy; Jejunum; Intestinal obstruction
Duodenal duplication cyst is a rare anomaly, totaling only 4% to 12% of gastrointestinal duplications, and is usually encountered during infancy or in early childhood. Most are commonly located posterior to the first or second portion of the duodenum. Presenting signs and symptoms include vomiting, decreased oral intake, periumbilical tenderness, abdominal distention, obstructive jaundice, acute pancreatitis, and gastrointestinal bleeding. The traditional treatment of a duodenal duplication cyst has been complete surgical resection, but very few cases of endoscopic treatment have been reported in the literature. Here, we report a case of duodenal duplication cyst that was manifested by a duodenal polyp.
Duodenum; Duplication cyst; Endoscopic resection
Adult intussusception is a rare entity accounting for only 5% of all intussusceptions and causes approximately 1% of all adult intestinal obstructions. Unlike paediatric intussusceptions which are usually idiopathic, there is usually a lead point pathology which might be malignant in up to 50% cases. We present an unusual case of adult intussusception which was not diagnosed on any investigation including computerized tomographic (CT) scan and magnetic resonance imaging (MRI). It was a case of ileo-ileo-cecal intussusception caused by a large lipoma 38 mm × 43 mm × 61 mm. It was treated by emergency laparotomy for acute intestinal obstruction. A conservative resection with ileostomy was performed with good postoperative recovery.
An unusual case of cecal volvulus arising from a strangulating fallopian tube is presented. The etiology, diagnosis, and management guidelines of this infrequent cause of large bowel obstruction are reviewed. Computed tomography images are included, which demonstrate key features that are pathognomonic for this condition. To our knowledge, this is the first report of gynecologic adnexa giving rise to cecal volvulus.
Cecal volvulus; Gynecologic and general surgery; Intestinal obstruction
Intestinal duplication in an adult is an uncommon congenital abnormality because only minority of cases present in adulthood. More than 80% of cases occur before the age of two years as an acute abdomen, bowel obstruction or other complications associated with it. Duplication has two types, either cystic or tubular. Here, we report a case of an adult who was diagnosed preoperatively on CT scan as tubular intestinal duplication. CT images showed change in the morphology of the cystic mass after one week of antibiotics administration. On histopathological analysis, the resected duplicated segment had esophageal epithelium in addition to the intestinal gland. So far, we found no report describing CT findings of dynamic change of ileal duplication in the English literatures.
Duplication of alimentary tract is one of the rare congenital anomalies. A case of duplication cyst of the cecum, presented in the 3rd month of life, as intestinal obstruction. Excision of the cyst along with cecum and appendix was done. The child had an uneventful postoperative recovery following ileoascending anastomosis.
Caecal duplication cyst; Intestinal obstruction
Mesenteric cysts are rare intra-abdominal tumors. Mesenteric cysts are usually asymptomatic and are incidentally detected during physical or radiological examination. Although uncommon, complications such as infection, bleeding, torsion, rupture and intestinal obstruction cause an acute abdomen. Spontaneous infection is a very rare complication. We present a case of infected mesenteric cysts in the ascending colon, which caused an acute abdomen. A 26-year-old woman was admitted to our hospital with acute abdominal pain. She had a painful mass in the right abdomen on physical examination. Abdominal computed tomography showed a hypodense cystic mass with septation at the mesenteric region of the ascending colon. A laparotomy revealed two cystic tumors at the mesenteric region of the ascending colon. She underwent a right hemicolectomy. The two cysts were filled with a yellowish turbid fluid. The walls of both two cysts were lined with a thin fibrotic membrane without any epithelial cell. They were diagnosed as psuedocysts with E. coli infection. Mesenferic cysts may cause life-threatening complications. Mesenteric cyst, even if it is asymptomatic and was diagnosed incidentally, should be removed completely.
Mesenteric cyst; Infection; Abdomen, acute
Gastrointestinal duplications are an uncommon congenital abnormality that manifest before the age of two in 80% of cases. Ileal duplication is the most common while colonic duplication, either cystic or tubular, occurs in 10%-15% of cases and remains asymptomatic and undiagnosed in most cases. Mostly occurring in pediatric patients, colonic duplication is encountered in adults in only a few cases. The most common clinical manifestations are abdominal pain and intestinal obstruction. Rarely, duplications present with signs of acute abdomen or acute bleeding. This study reports a case of colonic duplication in an adult who presented with chronic constipation. Complete diagnostic workup was made on several occasions during the previous eight year period, but no pathology was found and chronic constipation was attributed to hypothyroidism caused by long standing Hashimoto thyroiditis. Multislice CT, performed because of abdominal distension, defined colonic pathology but the definite diagnosis of duplication of the transversal colon was made at operation. The cystic duplication and the adjacent part of the ascending and transversal colon were excised en-block. This study implies that colonic duplication, though uncommon, should be included in the differential diagnosis of chronic constipation even when precipitating factors for constipation, such as hypothyroidism are present.
Colonic duplication; Constipation; Abdominal distension; Hypothyroidism
Colonic lipomas are rare nonepithelial tumors that are usually detected incidentally during surgery or colonoscopy. Although lipomas generally remain asymptomatic, when they exceed 2 cm of diameter they may cause abdominal pain, obstruction, or intussusception. Here we present a case of an elderly woman referred by her general practitioner to a general hospital of Crete because of acute abdominal pain along with signs of intestinal obstruction and a positive history of appetite loss. Abdominal computed tomography was performed. To marginalise the risk of malignancy, a right hemicolectomy was performed. Histopathological examination of the resected specimen confirmed the diagnosis of cecal lipoma.
To investigate whether neonatal dacryocystoceles and dacryocystitis are associated with nasolacrimal duct cysts, and to report the outcomes of treatment of these disorders.
This was a retrospective medical record review of two groups of infants with nasolacrimal duct (NLD) obstruction. The first group had dacryocystoceles with or without dacryocystitis. The second group had NLD obstruction with symptoms severe enough to require early NLD probing. All of the patients underwent NLD probing and nasal endoscopy. When present, NLD cysts were removed.
In the first group, 33 infants had dacryocystoceles. Acute dacryocystitis was present in 16 patients, 12 had noninfected dacryocystoceles that did not resolve, and 5 had dacryocystoceles that resolved but severe symptoms persisted. All of the patients had NLD cysts that were surgically removed. The symptoms resolved after surgery in 31 patients (94%). In the second group, 27 infants less than 6 months old without dacryocystoceles underwent early NLD probing and endoscopy due to severity of symptoms. Twelve (44%) of these patients had NLD cysts. The symptoms resolved in 11 (92%) of 12 patients following NLD probing and cyst removal.
Neonatal dacryocystoceles are almost always associated with NLD cysts. The success rate of NLD probing and endoscopic cyst removal in these patients is excellent. Nasolacrimal duct cysts also are present in many young infants with severe symptoms of NLD obstruction. Nasal endoscopy is an important adjunct to the management of these infants.
Acute appendicitis, as well as intestinal obstruction, is a common surgical emergencies. Both the conditions can present as an acute abdomen, however the diagnosis of acute appendicitis can be overlooked when it presents as a small bowel obstruction. Difficulties in correctly identifying the cause of pain can be hazardous to the patient and care needs to be taken in obtaining a prompt and accurate diagnosis enabling the most appropriate management. Appendiceal duplication although rare and difficult to diagnose preoperatively, should be checked while operating for appendicular pathology in order to avoid serious clinical and medicolegal implications.
We hereby report a case of appendiceal duplication presenting as small bowel obstruction with one appendix having acute appendicitis and the other one perforated in the middle third.
This report describes the occurrence of a cecal bascule (cecal volvulus) following laparoscopic ventral hernia repair and notes that the consequences of this complication can be serious.
We present a case of a cecal bascule, a rare type of cecal volvulus, as a complication of a laparoscopic ventral hernia repair.
A 73-y-old male with a ventral hernia underwent an uneventful elective laparoscopic repair. He developed an acute abdomen on postoperative day 6, and imaging demonstrated a cecal bascule. Exploratory laparotomy revealed a cecal bascule with an ischemic and perforated cecum, and a right hemicolectomy was performed.
Laparoscopic tension-free ventral hernia repairs have become more common, especially for obese patients. We discuss some risk factors that can predispose a patient to having a cecal volvulus postoperatively. Although cecal volvulus is a very rare complication after laparoscopic surgery, it can result in serious complications.
Cecal bascule; Cecal volvulus; Laparoscopic ventral hernia repair
Duodenal duplication cysts are rare congenital abnormalities that are most commonly diagnosed in infancy and childhood. However, in rare cases, the lesion can remain asymptomatic until adulthood. An extremely rare case of a previously healthy adult patient with recurrent acute pancreatitis, who was diagnosed with a duodenal duplication cyst is presented. At laparotomy, a duplication cyst measuring 4.8 cm × 4 cm × 4 cm was found adjacent to the ampulla of Vater. A partial cyst excision and marsupialization into the duodenal lumen was performed. The patient is healthy and asymptomatic four years after surgery. The present case illustrates the necessity of considering a duodenal duplication cyst in the differential diagnosis of recurrent acute pancreatitis in previously healthy adults.
Congenital anomalies; Duodenal duplication cyst; Pancreatitis; Recurrent
Chylolymphatic mesenteric cysts are rare entities with variable presentations and this has surgical implications in the pediatric age group.
We carried out a retrospective analysis of the clinical and histopathological records of pediatric patients diagnosed and treated for chylolymphatic mesenteric cysts at our institute from 1998 to 2008. Eight patients met the histopathological criteria of chylolymphatic mesenteric cyst. These patients were in the age range 18 months to 10 years with a mean age of 4.5 years. Of these eight patients, four presented with an abdominal lump, and two each with abdominal pain and acute intestinal obstruction. On clinical examination, five out of the eight patients had a palpable abdominal mass. Laparotomy and complete excision of the cyst along with the involved gut was performed in all patients. There were no postoperative complications or any recurrence during the follow-up period which ranged from 4 months to 8 years.
Although very rare, chylolymphatic mesenteric cyst should be kept in mind as one of the differential diagnoses of cystic masses of the abdomen including cystic lymphangioma. Ultrasonography and computed tomography suggest the diagnosis but histopathological examination is required for confirmation. Complete excision of the cyst yields excellent results.
A duodenal duplication cyst is an uncommon congenital anomaly that is usually encountered during infancy or in early childhood. Duodenal duplication cysts generally appear on the first or second portion of the duodenum and may cause duodenal obstruction, hemorrhage or pancreatitis. Here, we report a case of a duodenal duplication cyst on the second and third portion of the duodenum in an old aged man with obstructive jaundice and acute pancreatitis, which was treated successfully by a surgical excision.
Abnormalities; Duplication Cyst; Duodenum; Pancreatitis, Acute Necrotizing; Jaundice, Obstructive
Intestinal duplications are rare developmental abnormalities that may occur anywhere in the gastrointestinal tract. The possibility of a malignant change occurring in these duplications is very low. We present a case of adenocarcinoma arising in a duplication of the cecum. A 41-year-old male patient was admitted because of a palpable abdominal mass. Abdominal computed tomography revealed a 6-cm, peripheral wall-enhanced, round, cystic mass in the cecal area. Excision of the mesenteric mass and a right hemicolectomy was performed. Upon histologic examination, the patient was diagnosed with adenocarcinoma arising in a duplication of the cecum.
Adenocarcinoma; Cecum; Congenital abnormalities
Omental cyst are rare abdominal lesions and are difficult to diagnose. They are detected incidentally during imaging studies performed for unrelated reasons. In children, it may present as an acute abdomen due to intestinal obstruction or painless abdominal swelling. Imaging is helpful in excluding other causes of lump abdomen. We encountered a case of giant omental cyst presenting with abdominoscrotal swelling in a child. The patient underwent laparotomy and the diagnosis of omental cyst was established by intraoperative findings. Thus complete excision of the cyst was performed. The diagnosis was confirmed by pathological examination.
Abdominal swelling; abdominoscrotal swelling; child; chylolymphatic cyst; omental cyst
Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Rarely, patients may experience symptoms secondary to the cysts. The pathogenesis of pneumatosis cystoides intestinalis is still unclear and many theories have been advocated to explain the exact origin. Complications occur in about 3% of cases and include obstruction, intussusception, volvulus, haemorrhage and intestinal perforation.
The author reported a male patient aged 56 years presented to the emergency department with acute upper abdominal pain. Widespread variable sized serosal intestinal air cysts were seen at the first look involving long segment of jejunum and ileum. Perforated duodenal ulcer, as the cause of generalized peritonitis, was repaired with direct closure and omental patch. A second laparotomy, was done and exploration was systematically performed and denoted hugely distended stomach with cicatrisation at the site of previous closure of perforated duodenal ulcer and the whole length of small gut was completely free from the already described pneumatosis cystoides intestinalis.
The pneumatosis cystoides intestinalis is a rare disease and suspicion of this disease process should be based on imaging and clinical finding. The therapy can be conservative or surgical in restricted situations.
Vallecular cyst is a rare cause of upper airway obstruction in infants and children and presentation like acute stridor with near fatal respiratory distress is extremely rare. It is one of the rare causes of difficult intubation, during which cyst aspiration can improve the access. Vallecular cyst is commonly managed using microlaryngoscope and specialized instruments. We hereby report a method of endoscopic management of these cysts using conventional laparoscopic instruments.
Endoscopic management; respiratory distress; vallecular cyst
Cecal volvulus is uncommon in pediatric patients and there are few reports of cecal volvulus with cerebral palsy. Here, we report the case of a 19-year-old male patient who presented with abdominal distension, a history of cerebral palsy, refractory epilepsy due to lissencephaly, and chronic constipation. An abdominal x-ray and computed tomography without contrast enhancement showed fixed dilated bowel intensity in the right lower abdomen. Despite decompression with gastric and rectal tube insertion, symptoms did not improve. The patient underwent an exploratory laparotomy that revealed cecal volvulus. Cecal volvulus usually occurs following intestinal malrotation or previous surgery. In this patient, however, intestinal distension accompanying mental disability and chronic constipation resulted in the development of cecal volvulus. We suggest that cecal and proximal large bowel volvulus should be considered in patients presenting with progressive abdominal distension combined with a history of neuro-developmental delay and constipation.
Cecum; Inteseinal volvulus; Lissencephaly