Gastric duplication cyst
A healthy looking, Europian lady, patient presented with vague pain in abdomen of few days duration. Otherwise asymptomatic. She is a globe tattler and has traveled extensive included places in est Asia. There is no gastric symptoms. Pat history is remarkable for irregular menses and a D & C done for an endometrial polyp. She is unmarried.
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There is evidence of a well-demarcated hypo-attenuating lesion in the left supra-renal region measuring approximately 6cm in AP dimension, 4.4cm in transverse dimension and 6.8cm in craniocaudal dimension. The lesion shows slightly irregular shape but well demarcated margins. It shows well-encapsulated and well-defined wall. The internal contents of lesion appears to be homogeneously hypo-attenuating and are in the range of 20 to 30HU. The peripheral interfaces are well-maintained. The post contrast images revealed no evidence of an internal enhancement or any evidence of enhancing solid nodule within this lesion. The wall of the lesion shows gradual but persistent uptake of contrast with most conspicuous enhancement noted in the delayed (approximately 15 minute) images- which revealed smoothly enhancing and well-defined wall ranging in thickness of 3mm to 4mm. Lesion appears to have two areas of outward projection, one located on postero-superior aspect and the other located in inferior/ left lateral aspect of the main cyst. No internal septation or any obvious daughter cyst detected is seen. No mural calcification is seen.The lesion shows following relationships-:
Posteriorly, the lesion is mostly related to the posterior crus of the left hemidiaphragm; however, posteriorly and inferiorly it is also intimately related with the left adrenal gland which appears to be predominantly compressed and displaced towards the vertebral column by this cyst.
Anteriorly and superiorly, the lesion is related with the greater curvature of stomach and is extending/bulging into the lesser sac. The interface with the stomach also appears to be maintained and the lesion appears to be crossing smooth bulge/pressure effect over the greater curvature of stomach with well defined and unaltered mucosal lining of the stomach.
Anteriorly and inferiorly, the lesion is related to the tail of the pancreas but appears to have well-defined interface with pancreatic parenchyma. Medially, the lesion is related to the splenic hila and the spleen. The surrounding fat planes are well maintained.
The splenic vein is smoothly displaced inferiorly by the lesion.The interface of the lesion with all the surrounding parenchymal structure appears to be well maintained; however, the lesion is in maximum contact with the left adrenal gland indicating possibility that the lesion might be originating from the adrenal gland. However, lesion may also be present in the retroperitoneum and bulging into lesser sac and might be just abutting the adrenal gland rather than arising from it. Another well-defined similar appearing but clearly separate lesion is also noted in the left subdiaphragmatic region, adjacent to the fundus portion of the stomach. This lesion is seen bulging in to fundus portion of stomach and is measuring only approximately 16mm x 8.6mm, laterally it is related to the upper pole of the spleen. It shows similar morphology and contrast enhancement pattern as of the above described larger cystic lesion.Although, the above described lesions are intimate relation with the left hemidiaphragm but left hemidiaphragm appears to be otherwise appears normal.No calcification or any evidence of hemorrhagic component noted in either of the lesion. The underlying left adrenal gland otherwise appears normal. The right adrenal gland is seen normally. Bilateral kidneys show normal appearance without any definite focal lesion.The splenic parenchyma appears to have normal appearance.Liver shows normal enhancement and appearance.Pancreatic duct and CBD appears to be normal. No pancreatic calcification noted. The peripancreatic fat planes are normal. There is evidence of an approximately 23mm x 8mm lymph node between the IVC and the route of the superior mesenteric artery. 2-3 lymph nodes also noted adjacent to the celiac trunk.
TVS correlation ruled out any significant abnormality in the pelvis except for thickened endometrium.
Based in the radiological findings, a Differential diagnosis of Diaphragmatic cyst / Bronchogenic cyst may be proposed. The multiplicity of the lesions, suggests, need to consider the possibility of Hydatid cyst- a possibility aslo supported by history of frequent travels and visit to the east Asian countries. The Adrenal /pancreatic/splenetic origin can be ruled out. The origin from diaphragmatic crus/ stomach wall or retro peritoneal tissue is the reasonable consideration which should be kept in mind. Possibility of cystadenoma was considered prior to surgery, but multiplicity and lack of wall irregularity or solid component argued against this possibility.
A preoperative endoscopy failed to reveal any communication with the stomach lumen. The endoscopy revealed smooth indentation over the mucosa.
Patient underwent surgery- which revealed origin from the stomach wall- thus rendering the diagnosis of (Multiple) Gastric duplication cyst.
HPE report: The section showed cyst wall composed of mucosa, submucoasa and muscularis mucosa. The mucosa was predominantly of gatric body type in the main cyst. The mild chronic iniflammation was seen in the lamina propria. The other cyst was lined by columnar cells with areas of mucin secreting epithelium. Thus diagnosis of (Multiple) Gastric Duplication cysts was rendered. (Credits: Dr. Niti Singhal, Bright Point Hospital, Abu Dhabi Email: firstname.lastname@example.org )