Case Report
Copyright ©2008 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Feb 14, 2008; 14(6): 966-968
Published online Feb 14, 2008. doi: 10.3748/wjg.14.966
Colonic duplication in an adult mimicking a tumor of pancreas
Fabiana Pirani Carneiro, Maria de Nazareth Sobreira, Ana Emília B de Azevedo, Andréa Pedrosa Ribeiro Alves, Karina Martins Campos
Fabiana Pirani Carneiro, Maria de Nazareth Sobreira, Ana Emília B de Azevedo, Department of Pathology, University of Brasília, DF, Brazil
Andréa Pedrosa Ribeiro Alves, Karina Martins Campos, Department of Surgery, University of Brasília, DF, Brazil
Author contributions: Carneiro FP writes the paper; Sobreira MN and Azevedo AEB established histopathological diagnosis; and Alves APR and Campos KM performed the surgery.
Correspondence to: Dr. Fabiana Pirani Carneiro, Centro de Anatomia Patológica, HUB/ UnB, Via L2 Norte, SGAN 604/605, Módulo C, 70840-050 Brasília, DF, Brazil.
Telephone: +55-61-34485499
Fax: +55-61-34485560
Received: September 13, 2007
Revised: December 12, 2007
Published online: February 14, 2008


Duplications of the alimentary tract are uncommon congenital malformations that can present diagnostic difficulties. We report a rare case of a cystic colonic duplication in a female adult. Preoperative investigations were suggestive of pancreatic tumor. The diagnosis was established based on the histopathological examination of the resected specimen. We concluded that, though uncommon, intestinal duplication should be considered in differential diagnosis of abdominal mass.

Key Words: Intestinal duplication, Ectopic gastric mucosa, Pancreatic tumor, Congenital malformations, Abdominal mass

Citation: Carneiro FP, Sobreira MDN, Azevedo AEBD, Alves APR, Campos KM. Colonic duplication in an adult mimicking a tumor of pancreas. World J Gastroenterol 2008; 14(6): 966-968

Duplications of the alimentary tract are uncommon congenital malformations that can occur anywhere in the tract, and are most commonly detected in childhood. Depending on the age of patient, localization, size and shape of the duplications, they may present a diagnostic challenge[1]. We report a rare case of a cystic colonic duplication in an adult mimicking a tumor of the pancreas.


A 43-year-old woman was admitted with a 2-mo history of abdominal pain and mass. Ultrasonography (US) and computerized tomography (CT) showed a cystic mass (Figure 1) in left upper abdomen. In laboratory studies, serum amylase level was elevated at 332 U/L (normal, 0-125 U/L). The preoperative diagnosis was pancreatic tumor and fine needle aspiration biopsy was not performed preoperatively. At laparotomy, a mass was found in the mesenteric border of the transverse colon attached to the colon and pancreas. A distal pancreatectomy was performed with resection of the cyst. On gross examination, the cyst was 6 cm in diameter and contained a serous fluid (Figure 2). Microscopically, the cyst was lined by ulcerated gastric mucosa, submucosa and muscular wall (Figure 3); pancreatic tissue was normal. The patient’s pain improved following surgical resection of the mass.

Figure 1
Figure 1 Ultrasonography demonstrating a cystic lesion.
Figure 2
Figure 2 Surgical specimen including distal pancreas and the cyst.
Figure 3
Figure 3 Histological section of the cyst wall. A: Ectopic gastric mucosa with gastritis (HE, × 100); B: Ectopic gastric mucosa with ulceration (HE, × 25).

Duplications of the alimentary tract are characterized by attachment to at least one part of the tract, a layer of smooth muscle and epithelial lining resembling some part of the tract[2]. These malformations are formed before differentiation of the lining epithelium, and therefore, are named depending on the associated part of the bowel and not according to the mucosal lining[3]. Gastric mucosa, for example, is frequently observed in the wall of duplications, irrespective of their site of origin in the alimentary tract[4]. The duplications are located on the mesenteric border of the associated native bowel, vary in size and shape (cystic or tubular) and communicate or not with the lumen of the adjacent bowel; the duplication of cystic type usually does not communicate with the lumen of the adjacent bowel and contains serous fluid[1]. In the present case, the duplication was cystic and there was no communication with lumen of the colon.

The diagnosis of intestinal duplication may be difficult and usually is not made preoperatively. The patient may remain asymptomatic or present with a variety of nonspecific signs and symptoms[5]. Similar to our case, these signs and symptoms usually include abdominal mass and pain, often confusing colonic duplication with other diagnoses. Intestinal obstruction[6], bleeding[7] and malignant transformation[8] are all recognized complications. Ulceration, perforation and peritonitis may also occur in cases with ectopic gastric mucosa[9], which is probably the cause of ulceration in our case. In addition, various urogenital and vertebral malformations have been reported but, in the present report, no associated congenital abnormality was observed[5].

In our case, elevated serum amylase, probably owing to compression of the pancreatic duct, associated with the findings of US and CT were suggestive of pancreatic cyst, but some image findings may be helpful in establishing preoperative diagnosis of intestinal duplication. On US, the duplication is characterized by “gut signature” which refers to the hiperechoic inner layer produced by the mucosa surrounded by a hypoechoic outer layer caused by smooth muscle[10]. Peristalsis of the cyst wall has also been noted on ultrasound scan[11]. Contrast barium enema may show communication between the duplication and the normal bowel, with opacification of the two colons[12]; the communication between the duplication cyst and main pancreatic duct may be seen by endoscopic retrograde cholangiopancreatography[13]. Besides this, technetium scan may demonstrate ectopic gastric mucosa in duplication[14].

Previous reports[1517] have described gastrointestinal duplications mimicking pancreatic tumor. Among them, a case of transverse colon duplication in a child, like in our case, was not suspected before surgery[18]. The differential diagnosis includes in these cases, all neoplastic and non-neoplastic cystic lesions of the pancreas as intraductal papillary-mucinous neoplasm and pseudocyst[19].

The recommended treatment for duplication is complete resection. Sometimes resection of normal intestine must accompany removal of the lesion because of the intimate attachment of the common wall or because isolated resection would compromise blood flow to the adjacent intestine segment[20]. Generally, duplications of the cystic type are easily removed from their attachments to the surrounding tissues[21]. During surgery, diagnosis may be made based on the frozen sections examination of the wall of the duplication[22] but, in our case, it was not performed.

On histopathological examination, ectopic gastric mucosa showed chronic inflammation, lymphoid follicles and ulceration but no H pylori was identified in haematoxilin-eosin and Warthin-Starry silver stains. Previous reports about the role of H pylori in complications of the ectopic gastric mucosa in intestinal duplication were not found. But in most cases of ectopic gastric mucosa in Meckel’s Diverticulum, H pylori also is not identified and seems that its presence is not essential to induce “heterotopic gastritis” and its complications[2325]. In our case, the endoscopic examination was normal, and gastric biopsy was not performed.

In conclusion, we reported a case of cystic colonic duplication in an adult and illustrated the difficulties in making this rare diagnosis that should be considered in differential diagnosis of abdominal mass.


Peer reviewer: Dr. Massimo Raimondo, Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States

1.  Iyer CP, Mahour GH. Duplications of the alimentary tract in infants and children. J Pediatr Surg. 1995;30:1267-1270.  [PubMed]  [DOI]
2.  Macpherson RI. Gastrointestinal tract duplications: clinical, pathologic, etiologic, and radiologic considerations. Radiographics. 1993;13:1063-1080.  [PubMed]  [DOI]
3.  O’Neil J, Rowe M.  Duplications of the gastrointestinal tract. In: Essentials of Pediatric Surgery. St. Louis, Mo. MosbyYearbook; 1995;520-525.  [PubMed]  [DOI]
4.  Bajpai M, Mathur M. Duplications of the alimentary tract: clues to the missing links. J Pediatr Surg. 1994;29:1361-1365.  [PubMed]  [DOI]
5.  Blickman JG, Rieu PH, Buonomo C, Hoogeveen YL, Boetes C. Colonic duplications: clinical presentation and radiologic features of five cases. Eur J Radiol. 2006;59:14-19.  [PubMed]  [DOI]
6.  Jimenez SG, Oliver MR, Stokes KB, Morreau PN, Chow CW. Case report: Colonic duplication: a rare cause of obstruction. J Gastroenterol Hepatol. 1999;14:889-892.  [PubMed]  [DOI]
7.  Fotiadis C, Genetzakis M, Papandreou I, Misiakos EP, Agapitos E, Zografos GC. Colonic duplication in adults: report of two cases presenting with rectal bleeding. World J Gastroenterol. 2005;11:5072-5074.  [PubMed]  [DOI]
8.  Shivnani AT, Small W Jr, Benson A 3rd, Rao S, Talamonti MS. Adenocarcinoma arising in rectal duplication cyst: case report and review of the literature. Am Surg. 2004;70:1007-1009.  [PubMed]  [DOI]
9.  Bazlul Karim AS, Matiur Rahman MD, Kamal M. Perforation of jejunal duplication lined with ectopic gastric mucosa. J Paediatr Child Health. 2004;40:649-650.  [PubMed]  [DOI]
10.  Barr LL, Hayden CK Jr, Stansberry SD, Swischuk LE. Enteric duplication cysts in children: are their ultrasonographic wall characteristics diagnostic? Pediatr Radiol. 1990;20:326-328.  [PubMed]  [DOI]
11.  Spottswood SE. Peristalsis in duplication cyst: a new diagnostic sonographic finding. Pediatr Radiol. 1994;24:344-345.  [PubMed]  [DOI]
12.  Rathi V, Singh S, Bhargava SK, Kaur N, Seth N. Diagnosis of tubular colonic duplication by barium follow-through study. Australas Radiol. 2005;49:157-159.  [PubMed]  [DOI]
13.  Luckmann KF, Welch RW, Schwesinger W, Oswalt C, Bannayan G. Symptomatic duodenal duplication cyst in an adult demonstrated by endoscopic retrograde cholangiopancreatography. Case report and literature review. Am J Gastroenterol. 1979;72:153-159.  [PubMed]  [DOI]
14.  Emamian SA, Shalaby-Rana E, Majd M. The spectrum of heterotopic gastric mucosa in children detected by Tc-99m pertechnetate scintigraphy. Clin Nucl Med. 2001;26:529-535.  [PubMed]  [DOI]
15.  D'Journo XB, Moutardier V, Turrini O, Guiramand J, Lelong B, Pesenti C, Monges G, Giovannini M, Delpero JR. Gastric duplication in an adult mimicking mucinous cystadenoma of the pancreas. J Clin Pathol. 2004;57:1215-1218.  [PubMed]  [DOI]
16.  Niehues R, Dietl KH, Bettendorf O, Domschke W, Pohle T. Duodenal duplication cyst mimicking pancreatic cyst in a patient with pancreatitis. Gastrointest Endosc. 2005;62:190-192.  [PubMed]  [DOI]
17.  Glaser C, Kuzinkovas V, Maurer C, Glattli A, Mouton WG, Baer HU. A large duplication cyst of the stomach in an adult presenting as pancreatic pseudocyst. Dig Surg. 1998;15:703-706.  [PubMed]  [DOI]
18.  Dutheil-Doco A, Ducou Le Pointe H, Larroquet M, Ben Lagha N, Montagne J. A case of perforated cystic duplication of the transverse colon. Pediatr Radiol. 1998;28:20-22.  [PubMed]  [DOI]
19.  Kosmahl M, Pauser U, Peters K, Sipos B, Luttges J, Kremer B, Kloppel G. Cystic neoplasms of the pancreas and tumor-like lesions with cystic features: a review of 418 cases and a classification proposal. Virchows Arch. 2004;445:168-178.  [PubMed]  [DOI]
20.  Holcomb GW 3rd, Gheissari A, O’Neill JA Jr, Shorter NA, Bishop HC. Surgical management of alimentary tract duplications. Ann Surg. 1989;209:167-174.  [PubMed]  [DOI]
21.  Ildstad ST, Tollerud DJ, Weiss RG, Ryan DP, McGowan MA, Martin LW. Duplications of the alimentary tract. Clinical characteristics, preferred treatment, and associated malformations. Ann Surg. 1988;208:184-189.  [PubMed]  [DOI]
22.  Siddiqui AM, Shamberger RC, Filler RM, Perez-Atayde AR, Lillehei CW. Enteric duplications of the pancreatic head: definitive management by local resection. J Pediatr Surg. 1998;33:1117-1120; discussion 1120-1121.  [PubMed]  [DOI]
23.  Ackerman Z, Peston D, Cohen P. Role of Helicobacter pylori infection in complications from Meckel's diverticulum. Dig Dis Sci. 2003;48:1068-1072.  [PubMed]  [DOI]
24.  Ergun O, Celik A, Akarca US, Sen T, Alkanat M, Erdener A. Does colonization of Helicobacter pylori in the heterotopic gastric mucosa play a role in bleeding of Meckel's diverticulum? J Pediatr Surg. 2002;37:1540-1542.  [PubMed]  [DOI]
25.  Chan GS, Yuen ST, Chu KM, Ho JW, Leung SY, Ho JC. Helicobacter pylori in Meckel's diverticulum with heterotopic gastric mucosa in a population with relatively high H. pylori prevalence rate. J Gastroenterol Hepatol. 1999;14:313-316.  [PubMed]  [DOI]