report gastric duplication cyst in an infant presenting with non-bilious vomiting · 2017-06-27 ·...

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Introduction

Vomitinginachildcanoccurduetovariousconditions. In the settingof anabdominalmasscombined with vomiting, the aetiology is likelya surgical problem. Duplication cysts of thealimentary tract can present with the abovefeatures. The gastric duplication (GD) cyst inparticularisanuncommonlesion,accountingfor4% of gastrointestinal tract duplications (1). Toqualifyasaduplicationcyst,thefollowingcriterianeedtobesatisfied:liningwiththegastrointestinalmucosa,attachmenttothegastrointestinaltract,andthepresenceofasmoothmusclecoat(2). This case report outlines the presentationandmanagementofaGDcyst.

Case Series

A 10-month-old baby girl presented withnon-bilious vomiting and an abdominal massthat had been present for 2 weeks. The childwasotherwisewell.Onexamination,therewasalarge,firm,non-tendermass,whichmovedwithrespiration,ontherightsideoftheabdomen.Thechild was well hydrated and was unremarkableuponsystemicexamination. Acysticmasswasidentifiedonanultrasoundscan. Computed tomography contrast showeda cystic swelling associated closely to bowelmesentery (Figure 1). A possible diagnosis ofmesenteric cyst was made. A cystic mass thatwas 8 × 6 cm in size, dumbbell-shaped, andarisingfromthegreatercurvatureofthestomach,consistentwithacysticduplication(Figure2),wasexcisedextramucosallywithoutgastricresection.A gastric lining inwhich all of the layers of the

Case Report

Submitted: 25May2011Accepted: 18Jul2011

gastro-intestinal tract had a typical appearancewas identified on histology, confirming GD cyst(Figure3). The childwasdischargedonpost-operativeday4andwaswellatthe6-monthfollow-up.

Discussion

The stomach ranksnext to the small bowelandtheoesophagusintheorderofoccurrenceofgastrointestinaltractduplications.Dependingonthelocation,thepresentationvariesfromgastricoutlet obstruction to asymptomatic occurrence(3). Pancreatitis has been reported to occur inthe uncommon event of communication of thelesionwiththepancreas(4).Ofnoteistheacutepresentation that can result from bleeding orperforation(5). Most GD cysts present in infancy andinfrequentlyinageextremes—inuteroandamongtheelderly (6,7). It issupposedlymorecommonin females. The baby girl in our case fits theepidemiology(8). Contraststudymayrevealindentationonthegastric wall, making identification possible (9).Computed tomography or magnetic resonanceimaging can help to localise the cyst to itsorigin,butmaynotalways,as inourcase.Plainradiography of the abdomen may sometimespresentfindingssuggestiveofGDcyst,includingsoft-tissue interposition between the gastricshadow and transverse colon (10). UncommonassociationsofGDcystincludelungsequestrationand multicystic kidney (11,12). Extramucosalexcisionwithpreservationoftheadjacentgastricwall is recommended, as was performed in ourcase. Surgical options include laparoscopic

Gastric Duplication Cyst in an Infant Presenting with Non-Bilious Vomiting

G Krishna Kumar

Pediatric Surgical Unit, Department of Surgery, Hospital Tengku Ampuan Afzan, 25100 Kuantan, Pahang, Malaysia

Abstract Inaninfantpresentingwithamassintheabdomenandnon-biliousvomiting,duplicationcyst needs to be considered in the list of differential diagnoses. Gastric duplication cyst is anuncommonoccurrence in children.Diagnosis isbasedonclinicalfindingsand imaging features.Surgicalexcision is safeandoffersacompletecure.The literaturerecommendsexcisioneven inasymptomaticcasesduetoisolatedreportsofmalignancyarisingintheduplicationcystinlaterlife.

Keywords:abdominal neoplasms, cyst, differential diagnosis, gastrointestinal tract, paediatrics, vomiting

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Case Report |Gastricduplicationcyst

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excisionandtheendoscopicapproach,dependingon the expertiseof the surgeonsand locationofthe lesion (13,14). The dumbbell appearance ofthe gastric duplication in our case was uniqueandhadnotbeendescribed in the literature. Inasymptomatic cases, excision is recommendedduetothepossibledevelopmentoftumourssuchas adenocarcinoma or carcinoid in the GD cyst(15). Antenatal diagnosis is sometimes possible,enablingexpectantmanagementinthepost-natalperiod after appropriate evaluation. Occurrencein the thoracic region has been documented asa rare finding. The embryological aetiology isproposed to be due to faulty separation of thenotochordfromtheendodermresultinginentericduplications(16,17). The diagnosis of GD cyst is to be kept inmind during evaluation of an infant with anabdominalmass and vomiting. Imagingmay behelpful but is not confirmatory. Excision withgastricpreservationisusuallypossible,offeringacompletecure.

Acknowledgement

The contributions of Dr Mubarak M,consultant radiologist, Hospital Kuantan, andDrKalavathyR,consultantpathologist,HospitalKuantan,arethankfullyacknowledged.

Correspondence

DrGKrishnaKumarMRCSEd,MCh(PediatricSurgery),FEBPSPediatricSurgicalUnitDepartmentofSurgeryHospitalTengkuAmpuanAfzan25100KuantanPahang,MalaysiaTel:+609-5133333Email:sasisang@rediffmail.com

References

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4. Katz W, Annessa G, Read RC. Gastric duplicationwith pancreatic communication. Presenting aspancreatitis.Minn Med.1967;50(8):1175–1179.

Figure 2: Dumbbell-shaped gastric duplicationcyst.

Figure3:Single-layercolumnarepitheliumwithunderlying gastric mucosal glands(haematoxylin and eosin staining,200×magnification).

Figure 1: Abdominal computed tomographyshowingcysticmassoccurringclosetothebowelmesentery.

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