Duodenal duplication cyst is an extremely rare congenital anomaly usually diagnosed in childhood. However, it may remain asymptomatic for a long period. In adults it usually manifests with symptoms related to complications as pancreatitis, jaundice, or intussusception. We present the radiology findings of a patient with a duodenal intussusception secondary to a duplication cyst. The usefulness of the magnetic resonance (MR) in this case is highlighted.
A 33-year-old woman with a history of intermittent jaundice was referred to our radiology department. She had complained of recurrent abdominal pain for 5 years. At the age of 30 years she had been diagnosed of cholelitiasis by an ultrasound performed in another centre. Her liver function tests were abnormal with slight elevation of bilirubin.
First an abdominal ultrasound was realized. It showed an intussusception involving the duodenum and proximal jejunum. An anechoic cystic lesion was observed inside the lesion (Figure
Abdominal ultrasound image depicts the typical image of intussusception with a simple cyst inside.
The study was continued with computed tomography with contrast and obtainment in portal phase, and after a complementary magnetic resonance (MR) with axial and coronal T2 weighted single-shot turbo spin echo, MR Cholangiopancreatography and contrast enhancement sequences were performed. Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid was used for the dynamic study. We realized vascular acquisitions and a delayed hepatobiliary phase. The axial CT images and T2 weighted sequences confirmed that the distal duodenum with surrounding fat, vessels, and the pancreatic head were invaginated into the proximal jejunum. Inside the intussusception a cystic lesion was also visualized. The stomach was not distended (Figures
Axial and coronal CT shows that the distal duodenum with surrounding fat, vessels, and the pancreatic head were invaginated into the proximal jejunum (curve arrow). The common bile duct is dilated (single arrow).
Coronal T2 weighted single-shot turbo spin echo RM image confirms the cyst (arrow) as the cause of intussusception and biliary dilatation.
MR Cholangiopancreatography reveals that the common bile duct (large arrow) and the main pancreatic duct (small arrow) are pulled down and leftward into the elongated duodenum.
Coronal multiplanar reformation Gd-EOB-DTPA enhanced T1 weighted 3D GRE image obtained 30 minutes after injection shows contrast material in bile duct and duodenal lumen. Not inside the cyst.
An image of the histological examination shows characteristic findings of a duplication cyst and a double muscle layer, with their mucosal and submucosal layers.
Duplication cyst is a rare congenital condition that forms during the embryonic period of alimentary tract development. Most cysts are 2 to 4 cm in size. They occur frequently in the distal ileum. Conversely duodenal duplication cysts are very uncommon and represent only 2 to 12% of all digestive tract duplications [
Duodenal duplication cysts are usually diagnosed in the childhood. However they may remain asymptomatic until adulthood. Clinical manifestations in adults of duodenal duplication cyst are usually nonspecific and may easily be misinterpreted. Abdominal pain, nausea, and vomiting are the most common symptoms. They can present with a complication, pancreatitis and cholestasis being the most frequent. Intussusception, gastrointestinal bleeding, and cyst infection are also common [
Intussusception in adults is rare and there is an underlying disorder in 90% of cases [
Imaging studies are essential for a preoperative diagnosis. An ultrasonography is usually the first imaging technique performed. The ultrasound depicts the pathognomonic bowel within the bowel of the intussusceptions and can show the cystic nature of the duplication cyst. The localization of intussusception usually changes during examination. Besides it may be possible to see peristalsis in the wall caused by the muscular layer [
A treatment is necessary when adults present with symptomatic intussusception. Open surgical intervention is the most common technique for duplication duodenal cyst. Complete excision is usually frequent. This is the treatment of choice in case of complicated cyst intussusception [
The authors Eduardo Torres Diez, Raúl Pellón Dabén, Juan Crespo Del Pozo, and Francisco José González Sánchez declare that there is no conflict of interests regarding the publication of this paper.