Ileal duplication cyst

Presenting an unusual case of a clinically stable nulliparous obese 20-year-old female with hirsutism, who presented with vague, dull, aching, intermittent upper abdominal pain, nausea and non-projectile vomiting for one month.

On palpation, mild tenderness was present at the RIF region.

The laboratory report showed mild leukocytosis with neutrophilia. The rest of the parameters were within normal limits. Plain erect radiograph showed no free air under diaphragm or abnormal air fluid level.

US

US finding was thick stratified walled well-defined, identical to bowel wall, anechoic cystic lesion measuring approximately 65 x 42 mm at right iliac fossa, possibly arising from terminal ileum, noted without e/o perilesional fat stranding or fluid collection or significant enlarged lymph nodes. The appendix was not visualised separately. The report was dispatched as a possibility of an ileal duplication cyst.

CT scan

For further confirmation and pre-operative planning, the patient underwent CECT abdomen with pelvis with positive oral contrast, showing a well-defined thick-walled non-enhancing cystic lesion, measuring approximately 37 x 28 mm, noted in the terminal ileum, just proximal to ileocecal region, protruding in the terminal ileal lumen. The appendix appears normal. The report was dispatched as an enteric duplication cyst.

Duplication cysts, also known as alimentary tract duplications, are congenital lesions of the gastrointestinal tract. Although the exact cause is still elusive, multiple theories have been put forward to explain its occurrence [1]. A diverse clinical presentation due to variations in location, size, presence of heterotopic mucosa, etc., makes the clinical diagnosis of these cysts challenging. Ultrasound, showing the gut signature sign is pathognomonic of a duplication cyst.

Cysts can be divided into cystic or tubular on the basis of their structural configuration. Cystic duplications are more common (80% of the duplications) and do not communicate with the bowel lumen [2]. The ileum, followed by the oesophagus, is the most common location for these duplication cysts. In this case, the lesion was cystic in structural configuration located at RIF near the ileum, making gut duplication cyst the first differential. A distinct characteristic of these lesions is the close approximation with some parts of the gastrointestinal tract. This important characteristic was seen in this case, where the lesion was located adjacent to bowel loops.

Complete resection is recommended once duplication has been identified in order to avoid further complications such as bowel obstruction, volvulus, intussusception, malignant degeneration and even perforation. The resection of the normal intestine must accompany the removal of the duplication because of the intimate attachment of the common wall or because isolated resection would compromise blood flow to the adjacent bowel [3].

Intraoperative findings

The patient underwent laparoscopic resection of the IC junction containing the cyst, later converted to open surgery due to the large size of the cyst, with ileo-ascending colon anastomosis under general anaesthesia. The patient was admitted for six days and was NBM (nothing by mouth) without any complications.

All patient data have been completely anonymised throughout the entire manuscript and related files.