CASE REPORT
INTRALUMINAL CONTRAST; A HINT FOR THE DIAGNOSIS OF
COMMUNICATING TYPE COLONIC DUPLICATION CYST
Ismail M. Kabakus, Deniz Akata
De partm e ntofRadiol
ogy, H ace tte pe Unive rs ity Sch oolofMe dicine , Ank ara, Turk e y
PJR January - March 2015; 25(1): 34-36
ABSTRACT
Dupl
ication cys tis a conge nitalanom al
y ofgas trointe s tinals ys te m . Al
th ough itis a be nign l
e s ion, in s om e cas e s
it caus e s obs truction by e ith e r its e l
f or due to intus s us ce ption. W e pre s e nt a pe diatric cas e w ith re curre nt
intus s us ce ption due to col
onic dupl
ication cys t. Al
th ough th e dupl
ication cys ts h ow e d typicals onograph ic fe ature s ,
ith ad intral
um inalh igh de ns ity due to pas s age oforalcontras tw h ich is a cl
ue to putth e diagnos is ofcom m unicating
type dupl
ication cys t.
Keywords: Dupl
ication cys t;com m unicating type ;CT;pe diatric;intus s us ce ption
Case Report
Eigh tye ar-ol
d patie ntw ith h is tory ofintus s us ce ption,
pre s e nte d to e m e rge ncy room w ith abdom inalpain,
vom iting, de fe cation probl
e m . H e h ad intus s us ce ption
3 m onth s ago, and w as tre ate d w ith w ate r s ol
ubl
e
contras tre duction. Afte r th e tre atm e nt, h e w as h os pital
iz e d for 5 days . During h os pital
iz ation pe riod,
th e re appe are d no oth e r com pl
ication s o h e w as
dis ch arge d w ith outany furth e r s tudy.
Th is tim e h e cam e to th e e m e rge ncy room w ith 3
days h is tory of abdom inalpain and vom iting. H is
l
aboratory te s ts s h ow e d e l
e vate d l
ive r e nz ym e s ALT:
1015 U/L, AST: 9 13 U/L, GGT: 114 U/L. Sonograph ic
e val
uation re ve al
e d pe riportall
ym ph ade nopath ie s ,
pe rich ol
e cys tic fl
uid, and incre as e d vas cul
arity of
gal
lbl
adde r w al
lw h ich w e re al
lcons is te ntw ith viral
h e patitis . Furth e rm ore invaginate d il
e oce calbow e l
s e gm e nt and m e s e nte ric l
ym ph ade nopath ie s w e re
s e e n. H e w as h os pital
iz e d for tre atm e ntand furth e r
e val
uation for th e re curre nt intus s us ce ption. AntiH AVIgM and IgG l
e ve l
s w e re h igh and h e h ad ye l
l
ow
s cl
e ra. H e h ad pal
l
iative tre atm e nt for h e patitis -A
and unde rw e ntw ate r s ol
ubl
e contras t re duction for
intus s us ce ption. A s e cond ul
tras ound (US) e val
uation
w as done w h ich did s h ow 3 x 2.5 cm h ype r-is oe ch oic
l
e s ion w ith th e w al
lre s e m bl
ing inte s tinalw al
ll
ocate d
adjace nt to as ce nding col
on (Fig. 1). Ente ric dupl
ication cys tand de rm oid tum or w e re in th e diffe re ntial
diagnos is . Com pute d tom ograph y (CT) w as s ugge s te d for de finitive diagnos is . CT re ve al
e d 3 x 3 cm
l
e s ion w ith s m ooth borde r l
ocate d w ith in th e w al
lof
as ce nding col
on (Fig. 2). Th e l
e s ion w as cons ide re d
to be th e re as on for re curre ntintus s us ce ption. Surgicalre s e ction w as pl
anne d afte r s om e tim e ne e de d
for h is ful
lre cove ry.
Tw o m onth s l
ate r, h e w as h os pital
iz e d for s urgical
re s e ction. H is l
aboratory te s ts w e re unre m ark abl
e.
H e h ad no s ym ptom . During ope ration s e cond l
um inal
cys tic m as s w as s e e n adjace nt to as ce nding col
on
w al
l
. Six cm col
on s e gm e nt w as re s e cte d w ith th e
l
e s ion. Th e re w e re no com pl
ication afte r s urge ry and
th e patie ntw as dis ch arge d one w e e k l
ate r. Surgical
m ate rialw e nt unde r m icros copic e xam ination. Th e
l
e s ion w as found to h ave inte s tinalw al
l
s and m ucos a.
Th e finaldiagnos is w as th e dupl
ication cys t.
Correspondence : Dr. Is m ailM . K abak us
De partm e ntofRadiol
ogy,
H ace tte pe Unive rs ity Sch oolofM e dicine ,
Sih h iye , Ank ara 06100, Turk e y.
Te l
: + 9 0 312 305 11 88
Em ail
: m ik dat05@ h ace tte pe .e du.tr
Subm itte d 13 April2015, Acce pte d 29 April2015
PA K I S TA N J OU R N A L O F R A D IO L O GY
PJR January - March 2015; 25(1)
34
Figure 1: Trans ve rs e s onografic im age ofabdom inalrigh tl
ow e r
q uadrant;A h ype r-is oe ch oic l
e s ion m e as uring 3 x 2.5 cm in s iz e
w ith num e rous h ype re ch oge nic foci is s e e n attach e d to th e w al
l
ofce cum . Ith as a cys tic appe rance due to th e s urrounding w al
l
re s e m bl
ing an inte s tinalw al
l
. Th e l
aye rs ofth e inte s tine can be
de l
inate d as ; s upe rficialm ucos a(ye l
l
ow ), m ucos a(l
igh tbl
ue ),
s ubm ucos a(re d), m us cul
aris propria(gre e n). B adjace ntto
as ce nding col
on(as te rix)
Figure 2: A axialB coronalre form atte d CT im age s w ith intrave nous
and oralcontras t;w e l
l
-circum s cribe d l
e s ion (arrow ) adjace ntto
as ce nding col
on l
ocate d in th e righ tl
ow e r q uadrantw ith intral
um inal
h igh de ns ity (140 H U) due to contras tm ate rial
.
Discussion
Intus s us ce ption is one ofth e m os tcom m on caus e s
ofbow e lobs truction in pe diatric age group e s pe cial
l
y
up to 18 m onth s ofage , and ifnottre ate d, m ay l
e ad
to bow e lis ch e m ia due to vas cul
ar com pre s s ion
s tarting from ve nous ve s s e l
s , pe rforation and de ath .
It occurs w h e n a s e gm e ntofbow e linvaginate s into
a m ore dis tals e gm e nt, cl
as s ical
l
y at th e il
e oce cal
1
junction. Ifnottre ate d, ne cros is and /or pe rforation
of th e bow e lm ay occur. Up to 18 m onth s of age ,
e nl
arge d m e s e nte ric l
ym ph node s are us ual
l
yl
e ading
point. Afte r th at age , furth e r inve s tigation ne e ds to
be done for unde rl
ying caus e of intus s us ce ption as
in our cas e .2 Lym ph om a or gas trointe s tinals ys te m
conge nitalanom al
ie s m ay be th e re as on for intus s us ce ption atol
de r ch il
dre n.
Ente ric dupl
ication cys ts are rare conge nitalanom al
ie s aris ing anyw h e re al
ong th e al
im e ntary tract.
Ente ric dupl
ication cys ts are de fine d by th e ir h is tol
ogic
appe arance , w h ich m im ics th atofth e native gas tro-
PAK I S TA N J O U R N A L OF R A D I O LO GY
inte s tinaltract pos s e s s ing an inne r m ucos a-s ubm ucos a l
aye r s urrounde d by an oute r s m ooth -m us cl
e
e w al
lor “m us cul
ar rim ” s ign h as
l
aye r. 3 Th e doubl
be e n s ugge s te d to be ch aracte ris tic of dupl
ication
cys ts .4,5 Th e ch aracte ris tic s onograph ic appe arance
cons is ts of an inne r h ype re ch oic rim corre l
ating to
th e m ucos a–s ubm ucos a and an oute r s urrounding
h ypoe ch oic l
aye r re fl
e cting m us cul
aris propria.4,5
Th e CT findings of dupl
ications us ual
l
y incl
ude a
l
arge , w e l
l
-circum s cribe d, s ph e rical, or tubul
ar cys tic
m as s .6 Ente ric dupl
ication cys ts can be divide d into
tw o type s ;com m unicating or non-com m unicating.7
In our cas e itw as an e nte ric dupl
ication cys tl
ocate d
in il
e oce calre gion. Th e patie ntw as 8 ye ars ol
d w ith
re curre nt intus s us ce ption, both th e age and th e
re curre nce s h oul
d h ave be e n a w arning s ign to inve s tigate m ore about th e cas e . Al
th ough th e firs t US
e xam ination did notre ve alany oth e r path ol
ogy oth e r
th an invaginate d b ow e ll
oops and m e s e nte ric
l
ym ph ade nopath ie s , th e s e cond e xam ination afte r
th e tre atm e nt re ve al
e d h ype r- is oe ch oic l
e s ion
adjace ntto ce cum and as ce nding col
on. Th e l
e s ion
h ad inte s tinalw al
l
, th at w as cons is te nt w ith th e
diagnos is ofdupl
ication cys t. Al
th ough th e y are cys tic
in nature and us ual
l
y h ave l
ow de ns ity on CT;as in
our cas e , com m unicating type m ay s h ow h igh de ns ity
on CT w ith oral
l
y give n contras t and al
s o h ype ris oe ch oic on ul
tras ound be cau s e of th e com m unication be tw e e n true l
um e n ofcol
on and l
um e n of
dupl
ication cys t.
Conclusion
Intus s us ce ption is one ofth e m os tcom m on caus e s
ofinte s tinalobs truction in infancy and e arl
y ch il
dh ood
pe riod. Th is cas e re ve al
e d a dupl
ication cys tl
ocate d
il
e oce acal
l
y as th e caus e ofre curre ntintus s us ce ption.
Itis im portantto k e e p in m ind th atdupl
ication cys ts
m ay h ave de ns ity up to 140 H U on oralcontras t
give n CT e xam ination and h ype r-is oe ch oic appe arance on ul
tras ound w h e n itis com m unicating type .
Conflict of Interest: Th e auth ors de cl
are th atth e y
h ave no confl
ictof inte re s t
PJR January - March 2015; 25(1)
35
References
1. K ais e r, A.D., K .E. Appl
e gate , and A.P. Ladd, Curre nt s ucce s s in th e tre atm e ntof intus s us ce ption
in ch il
dre n. Surge ry, 2007. 142(4): 469 -75.
dis t, and J.E . Bine s ,
2. Ju s tice , F.A., A.W . Aul
Intus s us ce ption: tre nds in cl
inicalpre s e ntation
and m anage m e nt. J Gas troe nte rolH e patol
, 2006.
21(5): 842-6.
., M e s e nte ric and om e ntalcys ts :
3. Ros , P.R., e t al
h is tol
ogic cl
as s ification w ith im aging corre l
ation.
Radiol
ogy, 19 87. 164(2): 327-32.
, S.R., e t al
., Ul
tras onograph ic fe ature s of
4. Se gal
gas trointe s tinaldupl
ications . J Ul
tras ound M e d,
19 9 4. 13(11): 863-70.
oo, H ., e t al
., Ul
tras onic e val
uation of
5. K angarl
abdom inalgas trointe s tinaltract dupl
ication in
ch il
dre n. Radiol
ogy, 19 79 . 131(1): 19 1-4.
., Cys tic l
e s ions ofth e gas trointe s tinal
6. Le e , J., e tal
tract: m ul
tim odal
ity im aging w ith path ol
ogic corre l
ations . Kore an J Radiol
, 2010. 11(4): 457-68.
., Ente ric dupl
ication in ch il
dre n:
7. Liaq at, N., e t al
A cas e s e rie s . Afr J Pae diatr Surg, 2014. 11(3):
211-4.
PAK I S TA N J O U R N A L OF R A D I O LO GY
PJR January - March 2015; 25(1)
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