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Zainudin NZ, et al. Surg Chron 2018l 23(1): 58-59.
58
Jejunal Duplication Cyst: A rare presentation of intestinal obstruction in elderly
Nur Zawani Zainudin1, Nur Hidayati MPR2, Syed Hassan S1, Faezahtul AH2, Zaidi Z1, WM Mokhzani1
1 Department of Surgery, Hospital Universiti Sains Malaysia, Kelantan
2 Department of Pathology, Hospital Universiti Sains Malaysia, Kelantan
Abstract:
Duplication cyst is a rare congenital anomaly. Its incidence in gastrointestinal tract (GI) is only accounts for about 1% of all GI congen-
ital anomaly. It is commonly diagnosed in children up to 2 years old and its incidence in adults is very rare. Jejunum is the common-
est site for small bowel duplication cyst followed by ileal and duod enal. Its clinical presentation is varied and includes GI bleed, small
bowel perforations or intestinal obstruction. The management is therefore according to its presentation. We present a case of an
elderly who presented with intestinal obstruction. Intra-operative findings of jejunal duplication cyst with perforation. Although rare,
it still can present in elderly as it is commonly asymptomatic.
Keyword: Jejunal duplication cyst, elderly, management.
Introduction
Duplication cyst is a disease of the young and its incidence in
adult is very rare. Therefore, it is least expected diagnosis in
adult patients who presented with intestinal obstruction. Re-
gardless of age, if duplication cyst presented as its complica-
tions such as perforation, intestinal obstruction or bleeding,
surgery still the mainstay of the treatment.
Case presentation
70years old, female, complained of lower abdominal pain for
1 week duration. It associated with fever for 3 days, no bowel
motion and no passing out flatus for 2 days. She had persis-
tent vomiting for more than 10times per day for 1 day dura-
tion. Otherwise, she had no alternate bowel habit, no per
rectal bleed and no significant loss of weight.
On examination, she was alert with mildly dehydrated.
Blood pressure was 112/69mmHg, heart rate 85bpm, tem-
perature 39.1 degree Celcius. Upon abdomen palpation, there
was tenderness elicited at right iliac fossa, suprapubic and left
iliac fossa but no mass palpable. Bowel sound was sluggish.
Abdomen was resonance on percussion. Per rectal examina-
tion had no intraluminal mass. No palpable axillary and ingui-
nal lymph nodes.
Blood investigations taken showed normal range of total
white cells and hemoglobin 12g/dl. Coagulation profile was
normal in value. Arterial blood gases, electrolytes and blood
urea and creatinine were all normal in value. Plain radiograph
of chest showed haziness at right middle and lower zone. No
cardiomegaly and no air under diaphragm to suggest hollow
organ perforation. Abdominal Xray noted dilated small bowel
with absence of rectal gas. CT scan of the abdomen and pelvic
showed smooth abrupt jejunal narrowing (in axial view) with
presence of whirlpool sign. It had features of jejunal malrota-
tion and adjacent intra-abdominal collection.
Emergency laparotomy was done and noted that the prox-
imal jejunum was dilated and she had 2 duplication cysts with
one of the cyst had sealed perforation. The cyst was 20cm
from duodenojejunal (DJ) junction. The amount of bowel re-
sected was 50cm and jejuno-jejunal anastomosis was made.
The rest of the bowels were normal.
Figure 1: A gross specimen of jejunal resection showed 2 outpouch-
ing lesions with proximal to the lesion showed dilated bowel. One
of the lesion has perforation on it.
Postoperative patient was recovered well. She was dis-
charged at post-operative day 14. Histopathology reported as
Zainudin NZ, et al. Surg Chron 2018l 23(1): 58-59.
2
duplication cyst with no evidence of malignancy. Patient has
been follow up for 2 years after surgery and she was well with
no specific complaints.
Discussion
Duplication cyst is a congenital malformation of gastrointesti-
nal tract (GI) and was first reported by Calder in 1733. It
should have all these characteristics to define a duplication
cyst:-
1) Smooth muscle coat must be well-developed.
2) The epithelial lining must be similar to the GI tract.
3) It must attached intimately to some portion of the GI
tract.
Small intestine is the commonest site (34%), followed by
colon and gastric. Ileum is the commonest site followed by
jejunum and duodenum [1]. Synchronous GI duplications ac-
counts for 15% of cases [3]. The cyst can be either cystic in
nature (80%) or tubular (20%) [2].
Gross examination of excised specimen revealed two cyst-
ic masses measuring 7.5cm x 5cm x 6cm and 5cm x 4.5cm x
3cm, attached to the mesentery of intestine with gelatinous
mucoid material is seen within the wall. Histopathological
examination was diagnostic of duplication cyst lined by jeju-
nal type of epithelium (Figure 2).
Figure 2: (A) Duplication cyst wall lined by jejunal type of epitheli-
um shares a common muscular coat (arrow) with the jejunum. The
underlying submucosa is oedematous. (B) The jejunal-type epithe-
lial lining with underlying smooth muscle layer. (Hematoxylin &
Eosin (H&E) section, Original magnifications, A, x 40 and B, x 100).
About more than 60% of GI duplication cyst are diagnosed
prenatally or in the first 2 years of life therefore the occur-
rence of duplication cyst in adults are very rare.
Modes of presentations are varied from asymptomatic to
either intussuception, peritonitis secondary to bowel perfora-
tion or lower GI bleed. Malignant change is rare in duplication
cyst but there have been reported in literature including ade-
nocarcinoma, carcinoid or even squamous cell carcinoma [4].
In this case, we postulated that the intestinal obstruction
may be caused by the mass effect from the cyst to the adja-
cent small bowel. Since it shares the similar mucosa to the
adjacent bowel, fluid accumulation is probably due to in-
crease secretion of fluids or enzymes in the cyst wall. Once it
impinged on the adjacent bowel, it cause bowel dilatation
hence cause obstruction to the venous and arterial supply to
the respective bowel, which we believed to cause infarction
and therefore perforation.
In her age, it is difficult to predict malignant change intra-
operatively in which is suspected, should a wider margin
should be resected to prevent recurrent. Since the presenta-
tion is rare, most patients who have malignant changes were
in advanced state [4]. Therefore, curative resection is hard to
perform. Besides, it shares the similar mode of metastasis to
that of primary small bowel cancer. Most cases of malignant
change reported in an advanced age. In our patient, no ma-
lignant change was found and patient was follow up well after
2 years of surgery.
Conclusion
Duplication cyst still can present in adults and elders. It can
remain asymptomatic and can only be diagnosed once patient
presented with symptoms of intestinal obstruction, peritonitis
or bleeding.
References
1. Iyer CP, Mahour GH. Duplications of the alimentary tract in infants and
children. J Pediatr Surg. 1995 Sep. 30(9):1267-70.
2. Domajnko B, Salloum RM. Duplication Cyst of the sigmoid co-
lon. Gastroenterology Research and Practice. 2009.2009:918401
3. Kiratli PO, Aksoy T, Bozkurt MF, Orhan D. Detection of ectopic gastric
mucosa using 99mTc pertechnetate: Review of the literature. Ann Nucl
Med. 2009;23:97–105.
4. Kusunoki N, Shimada Y, Fukumoto S, Iwatani Y et al. Adenocarcinoma
arising in a tubular duplication of the jejunum. J Gastroenterol 2003,
38:781-785
Corresponding Author:
Nur Zawani Zainudin
Surgical Department, Hospital Universiti Sains Malaysia
Jalan Raja Perempuan Zainab 2, Kubang Kerian,
16150, Kota Bharu, Kelantan
Phone No: +609-767300
Fax No: +609-7671060
Email: zawanizainudin84@gmail.com
