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Arch Surg. 2005;140:1006.

Answer: Traumatic Intramuscular Cyst of the Duodenum
The patient underwent exploratory laparotomy with segmental resection of the third and fourth portions of the duodenum, which demonstrated an isolated cystic mass with evidence of hemorrhage distal to the descending (second) portion of the duodenum. The patient subsequently underwent duodenojejunostomy.

Pathological examination showed an intramuscular cystlike cavity lined with granulation tissue and 1 lymph node with no significant pathological abnormality. The muscularis propria of the duodenum was dissected by the cystic space, which contained features of hemorrhage; no epithelial lining was present. The findings were compatible with prior muscular hemorrhage consistent with blunt physical trauma.

The insidious nature of blunt duodenal injuries makes initial diagnosis difficult, potentially compromising patient care.¹ The predominantly retroperitoneal location of the duodenum offers protection but contributes to the difficulty in identifying injury, especially in individuals without abdominal complaints or with distracting injuries. Although an abdominal computed tomographic scan with both oral and intravenous contrast showed a cystic mass associated with the duodenum in this patient, blunt duodenal injury often has more subtle computed tomographic findings, such as pneumoperitoneum, unexplained fluid, and unusual bowel morphology—phenomena that should precipitate laparotomy.²

Given the initial examination and imaging studies, the initial differential diagnosis included intestinal duplication, pancreatic pseudocyst, and echinococcal cyst.^3-7 Duodenal duplication cysts may be asymptomatic for years before causing pain, distension, bowel obstruction, or gastrointestinal bleeding.^4-5 Although the cystic space of this patient was present within the native duodenal muscular layers, it was not lined by mucosa, ruling out duodenal duplication cyst.

Pancreatic pseudocysts result from pancreatitis or pancreatic trauma and are lined with granulation or fibrous tissue.⁸ Typically containing pancreatic juice or amylase-rich fluid, pseudocysts can be drained surgically or percutaneously.⁹ Pancreatic cystic tumors may be difficult to distinguish from other lesions, with at least 1 report of a gastrointestinal duplication mimicking a mucinous cystadenoma.¹⁰

Echinococcal cysts result from infection with Echinococcus granulosus, a zoonotic infection most prevalent in sheep-raising countries in Asia, Australia, South America, the Near East, and southern Europe. Most commonly affecting the liver, characteristic signs include calcification of the cyst wall and the presence of daughter cysts.¹¹ The combination of antihelminthic therapy with percutaneous aspiration, injection, and reaspiration using antiscolicidal and sclerosing agents has been found to be an effective treatment choice.¹²

The identification of blunt hollow viscus injury remains a diagnostic challenge among all age groups. These injuries are commonly occult on initial examination and the physician should maintain a high level of suspicion given the potential morbidity associated with the retroperitoneal location of the duodenum and its proximity to vital structures.

The patient did well and was discharged from the hospital on the fourth postoperative day.

Submissions The Editor welcomes contributions to the "Image of the Month." Send manuscripts to Archives of Surgery, Johns Hopkins Medical Institutions, 720 Rutland Ave, Ross 759, Baltimore, MD 21205; (443) 287-0026; e-mail: archsurg{at}jama-archives.org. Articles and photographs accepted will bear the contributor’s name. Manuscript criteria and information are per the "Instructions for Authors" for Archives of Surgery. No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

AUTHOR INFORMATION

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Correspondence: Hobart W. Harris, MD, MPH, Division of General Surgery, University of California, San Francisco, 513 Parnassus Ave, S-301, San Francisco, CA 94143-0104 (harrish{at}surgery.ucsf.edu).

Accepted for Publication: March 14, 2005.

REFERENCES

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1. Cuddington G, Rusnak CH, Cameron RD, et al. Management of duodenal injuries. Can J Surg. 1990;33:41-44. ISI | PUBMED 2. Allen G, Moore FA, Cox CS Jr, et al. Delayed diagnosis of blunt duodenal injury: an avoidable complication. J Am Coll Surg. 1998;187:393-399. FULL TEXT | ISI | PUBMED 3. Browning RW. Duodenal duplications. Rev Surg. 1963;20:226-229. PUBMED 4. Gross RE, Holcomb GW Jr, Farber S. Duplications of the alimentary tract. Pediatrics. 1952;9:448-468. 5. Rubin RB, Saltzman JR, Zawacki JK, et al. Duodenal duplication cyst with massive gastrointestinal bleeding. J Clin Gastroenterol. 1995;21:72-74. ISI | PUBMED 6. Macpherson RI. Gastrointestinal tract duplications: clinical, pathological, etiologic, and radiologic considerations. Radiographics. 1993;13:1063-1080. FREE FULL TEXT 7. Luckmann KF, Welch RW, Schwesinger W, et al. Symptomatic duodenal duplication cyst in an adult demonstrated by endoscopic retrograde cholangiopancreaticography: case report and literature review. Am J Gastroenterol. 1979;72:153-159. ISI | PUBMED 8. Andren-Sandberg A, Dervenis C. Pancreatic pseudocysts in the 21st century, part I: classification, pathophysiology, anatomic considerations and treatment. JOP. 2004;5:8-24. PUBMED 9. Morton JM, Brown A, Galanko JA, Norton JA, Grimm IS, Behrns KE. A national comparison of surgical versus percutaneous drainage of pancreatic pseudocysts: 1997-2001. J Gastrointest Surg. 2005;9:15-21. FULL TEXT | ISI | PUBMED 10. D’Journo XB, Moutardier V, Turrini O, et al. Gastric duplication in an adult mimicking mucinous cystadenoma of the pancreas. J Clin Pathol. 2004;57:1215-1218. FREE FULL TEXT 11. Kiresi DA, Karabacakoglu A, Odev K, et al. Uncommon locations of hydatid cysts. Acta Radiol. 2003;44:622-636. ISI | PUBMED 12. Smego RA, Bhatti S, Khaliq A, et al. Percutaneous aspiration-injection-reaspiration drainage plus albendazole or mebendazole for hepatic cystic echinococcosis: a meta-analysis. Clin Infect Dis. 2003;37:1073-1083. FULL TEXT | ISI | PUBMED

SECTION EDITOR: GRACE S. ROZYCKI, MD

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