Colonic Duplication Cyst Mimicking As a Cystic Pancreatic Tumour: Case Report and Review
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JOP. J Pancreas (Online) 2015 Sep 08; 16(5):487-491. CASE REPORT Colonic Duplication Cyst Mimicking as a Cystic Pancreatic Tumour: Case Report and Review Norman Oneil Machado, Shahzad Younas, Mohamed Abdel Rahim, Abdullah al Jabri, Adil al Zadjali Department of Surgery, Sultan Qaboos University Hospital, PO Box 38, Postal code 123, Muscat/ Oman ABSTRACT Cystic mass presenting in the right hypochondrium, could be a diagnostic challenge. These lesions could arise from pancreas, common bile duct, liver, stomach and colon. Establishing a preoperative diagnosis with certainty, despite the modern radiological imaging and of a young lady who presented with one year history of abdominal pain. computerized tomography and magnetic resonance imaging scan endoscopic facility may be difficult, particularly when it is due to an uncommon lesion like colon duplication cyst. We present here a case rightrevealed hypochondrium a large cystic andmass, highlight medial tothe the salient “C” loop features of duodenum, of colonic mimicking duplication a possiblecyst. cystic lesion of the pancreas. Resection of the lesion and histopathology revealed a duplication cyst of the transverse colon. We discuss the various differential diagnosis of cystic lesion in the INTRODUCTION Her complete blood picture (CBC), liver function tests (LFT), serum amylase and urea electrolytes results were Cystic lesions in the right hypochondrium often present as a clinical problem. Several probabilities arise, including a 9x7 cm cystic mass, arising medial to the duodenal loop the relatively common lesions related to the pancreas andunremarkable. adherent to CT the and pancreas, MRI scan greater of the curvature abdomen of revealedstomach [1, 2], cystic lesions of the liver [3] and the uncommon (Figure 1-3). choledochal cyst arising from the common bile duct The CBD and the pancreatic duct were normal and the cyst [4]. However, duplication cysts from the stomach [5, wasand hepaticnot communicating flexure. It had fewto them. fine septations Differential diagnosis 6] or transverse colon [6] presenting as a cystic right of pseudocyst of pancreas, mucinous cystadenoma and hypochondriac mass is extremely uncommon and is a gastric or colonic duplication cyst were entertained. She pancreaticdiagnostic enigma.lesion and We discuss present the here differential a case of diagnosis. duplication In was decompressedexplored with toright facilitate subcostal dissection incision and and 200 findings ml of addition,cyst of the we transversehighlight the colon pathology, in an diagnosticadult, mimicking challenge a consistent with CT findings were (Figureobserved. 4) . TheThe cyst and management issues related to duplication cyst arising was gradually separated from the duodenum , head of the from the transverse colon. pancreasamber coloured and greater fluid curvaturewas aspirated of the stomach. However Case report as it seemed to arise from the colon and being close to the A thorty-eight-year-old female patient was referred to our (Figure 5&6). The histopathology revealed cystic lesion unit with one year history of chronic upper abdominal arisinghepatic from flexure, the colona right with hemicolectomy features consistent was withcarried benign out pain. Her appetite was good, she had no weight loss and her bowel habit was normal. She was not febrile nor was she jaundiced. On examination, she was not anemic and ancyst uneventful with spindle recovery cell proliferation and was discharged with inflammation on the 7th post- and her vital signs were normal. Abdominal examination operativesclerosing day. fibrosis and areas of smooth muscle. Patient had revealed a non, tender, non-mobile, large mass in the right hypochondrium. There was no organomegaly. DISCUSSION Cystic mass in the right hypochodrium, could arise from Received April 25th, 2015-Accepted May 29th, 2015 different organs in that region, of which pancreas is the Keywords Pancreatic Cyst; Pancreatic Neoplasms Norman Machado Correspondence be considered in the differential diagnosis, based on the Department of Surgery most likely. Several cystic lesions of the pancreas could Sultan Qaboos University Hospital PO Box 38, Postal code 123 [8-11]. The most predominant differential diagnosis include Muscat/ Oman IPMN,patients mucinous age, clinical cystadenoma, presentation and serous radiological cystadenoma, findings Phone +00 968 99432723 simple cysts and pseudocysts related to acute or chronic E-mail [email protected] pancreatitis [1-2, 8-11]. IPMN is characterized by cystic JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 16 No. 5 – Sep 2015. [ISSN 1590-8577] 487 JOP. J Pancreas (Online) 2015 Sep 08; 16(5):487-491. features with IPMN [9]. However, in contrast to IPMN, which are cystic dilatations of the pre-existing ducts, MCN’s presumably form de novo cystic tumours [9]. They are characterised by an underlying ovarian type of stroma and could turn malignant [9]. Mucinous cystic neoplasms have distinctive clinicopathologic characteristics, including being exclusively seen in perimenopausal females(mean age 48 years; male to female ratio <1/20). The neoplasms is most often located in the tail of the pancreas [9]. Macroscopically, MCN’s are composed of large multilocular on the other hand are benign neoplasm composed of uniformcysts, which cuboidal, have thickglycogen fibrotic rich wall. epithelial Serous cells, cystadenoma typically presentforming asinnumerable relatively large small masses, cysts containing mostly in serousthe body fluid, or tailgiving of thea sponge pancreas like and gross are appearanceseen predominately [10]. They in femalesusually (male to female ratio; 1:3).The mean age of patients is 61 years and are invariably benign in nature [9]. Pseudocysts, that are much more common than the cystadenomas, Figure 1. CT scan revealing a cystic lesion medial to the duodenal loop. Fine septations seen on the superomedial aspect of the cyst are likely to be preceded by a history of acute or chronic (CEA),pancreatitis mucin [8]. and Radiological malignant imaging cells, couldand analysis differentiate of the betweenaspirated thesefluid pancreaticfor amylase, lesions carcino [8, embryonic11]. High amylaseantigen Endoscopic ultrasound(EUS) for presence of mural nodules levels in the aspirated fluid would suggest pseudocyst . and CEA levels may help in establishing the diagnosis , as theseand cyst would fluid be analysis elevated for in cytology, mucinous extracellular cystadenoma mucin and cysts,IPMN in[8, addition 11]. Radiological/endoscopicto the presence of papillary investigations process and intraductalthat confirm mucin, the presence is consistent of ductal with communicationthe diagnosis of ofIPMN the Cystic lesions of the liver could also present as right hypochondriac mass. Cystic hepatic lesions could be related lesions. The most commonly encountered lesions aredevelopmental, hepatic cysts, inflammatory, which are developmentalneoplastic and in traumanature They are most often asymptomatic and are incidental and are seen in 2.5% of the general population [3]. Figure 2. in the right hypochondrium infection or are symptomatic [3]. US will reveal a well MRI- T2 weighted - coronal view revealing a large cystic lesion marginated,findings and anechoicneed no treatmentstructure unlesswith enhancement complicated byof dilation of pancreatic ducts, in which an intraductal the posterior wall and increased through transmission. proliferation of neoplastic mucin producing cells is usually arranged in papillary pattern [8]. They could arise from HU) and reveal T1 hypointensity and T2 hyperintensity main duct, branch duct or both ducts(combined form) On CT and MRI, simple cysts have attenuation of (0-15 cases, based on the duct involved [8]. The papillae may shows[3]. Other multiple developmental cystic lesions lesion, in the like liver biliary with hamartoma, enhancing rangeand have from a microscopicrisk of turning to nodularmalignant masses in 46 [8]to 92%.The mucinof the “centralare uncommon dot sign”, [3]. which Caroli is thedisease portal on radicle CT scan . Moreover, or MRI production by the neoplastic cells is usually associated communication with the biliary tree may be revealed by with intraluminal mucin secretion, which leads to cystic preceded by a history of fever, are acute in nature and are MRI or ERCP. Inflammatory cystic lesions are generally diagnosticdilatation ofof theIPMN ducts. [8, 11].When They in excess, generally mucin present may indrain the Pyogenic abscess show complex cyst with enhancing rim from the ampulla of Vater, a finding that is virtually andassociated amoebic with abscess suggestive show clinical complex signs cyst and leukocytosis.with double symptoms. Mucinous cystic neoplasms share various target appearance due to a ring of odema around the well seventh to eight decade of life with non specific abdominal JOP. Journal of the Pancreas - http://pancreas.imedpub.com/ - Vol. 16 No. 5 – Sep 2015. [ISSN 1590-8577] 488 JOP. J Pancreas (Online) 2015 Sep 08; 16(5):487-491. they may present with abdominal mass, chronic abdominal pain, constipation, and less frequently with enhancing inflamed wall [3]. To differentiate between obstruction (volvulus, intussusception), bleeding, maypyogenic show and complex amoebic cyst abscess with mayperipheral be difficult daughter and is madecysts [3].based Neoplastic on the clinical cysts and are serological generally findings.biliary cystadenoma Hydatid cyst abdominal pain may depend on the type of duplication and cystadenocarcinoma