SPR Unknown # 95 -- FINAL

Jennifer Talmadge, MD

PGY-5

Maine Medical Center, Portland, Maine

Charles Grimes, MD

Section Co-Chief, Pediatric Radiology

Maine Medical Center, Portland, Maine

Andrew Landes, MD

Section Co-Chief, Pediatric Radiology

Maine Medical Center, Portland, Maine


Publication Date: 2013-08-25

History

Newborn girl followed for abnormal prenatal ultrasound, concern for duodenal atresia. A prenatal ultrasound is provided. An upper GI study was performed soon after birth. The nuclear medicine Meckel's scan and abdominal ultrasound were obtained at 5 months of age when the patient presented with guaiac positive stools and anemia requiring blood transfusions (hgb 5.0).

Findings

Prenatal ultrasound demonstrated a large fluid filled structure in the mid abdomen. This could not be clearly distinguished from the stomach, and the initial concern was that this could be a "double bubble" in the setting of duodenal atresia. The finding persisted on several follow up prenatal ultrasounds. The fetal survey was otherwise normal. At 2 days of life an upper GI study was performed which was normal. An abdominal ultrasound at 5 months of age showed a round fluid filled structure immediately adjacent to the stomach with "gut signature," consistent with a gastric duplication cyst. Also at 5 months of age, a nuclear medicine pertechnetate scan with SPECT demonstrated radiotracer uptake adjacent and posterior to the stomach, suggesting the presence of gastric mucosa within the duplication cyst. There was also radiotracer uptake by the normal gastric mucosa, as expected, which partially obscured the uptake within the duplication cyst. There was no evidence of a Meckel's diverticulum. An echocardiogram was normal.

Diagnosis

Gastric duplication cyst

Discussion

At laparoscopy, the duplication cyst appeared to drain into the pancreatic ductal system. There was also an esophageal duplication cyst and asplenia. Pathology confirmed gastric mucosa within the cyst.

Duplication cysts can occur anywhere along the alimentary canal, most commonly in the small bowel along the mesenteric border. The characteristic ultrasound appearance of gut mucosa includes an echogenic mucosal layer, hypoechoic muscular layer, and echogenic serosal layer. Gastric duplication cysts make up approximately 4-7% of all enteric duplication cysts and are most commonly located along the greater curvature. The cysts are usually lined with gastric mucosa which will pick up radiotracer on pertechnetate scintigraphy, as in our case. They can present with obstruction, hemorrhage, abdominal pain, or a palpable mass-- usually within the first year of life-- if not picked up on a prenatal ultrasound. A minority of gastric duplication cysts contain pancreatic tissue. Rarely there will be a communication between the duplication cyst and the stomach or the pancreatic ductal system, as in our case. The treatment is surgical resection.

Files

References

  1. Fefferman NR, Sudha SP Stomach: Congenital and Neonatal Abnormalities in: Coley BD ed. Caffey's Pediatric Diagnostic Imaging. 12th ed Philadelphia, PA: Elsevier Saunders; 2013:1032-3.
  2. Tong SC, Pitman M, Anupindi SA. "Best Cases from the AFIP Ileocecal Enteric Duplication Cyst: Radiologic Pathologic Correlation." Radiographics. 2002 Sept:1217-1222.
  3. Cheng G, Soboleski D, Daneman A, Poenaru D, Hurlbut D. "Sonographic Pitfalls in the diagnosis of enteric duplication cysts." AJR. 2005 Feb;184(2):521-5.

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