Duplication Cyst of the Duodenum as an Unusual Cause of Massive
Gastrointestinal Bleeding in an Infant
By Dan Arbell, Abraham Lebenthal, Arie Blashar, Alexander Shmushkevich
, and Eitan Gross
Duplication cysts of the gastrointestinal tract are rare and
very rarely present as massive intestinal bleeding. The au-
thors present a case in which massive bleeding was caused
by a bleeding duodenal duplication cyst and was treated
successfully by surgical excision. A review of the literature
also is presented.
J Pediatr Surg 37:E8. Copyright 2002, Elsevier Science (USA).
All rights reserved.
INDEX WORDS: Intestinal duplication, gastrointestinal
UPLICATION CYSTS of the gastrointestinal
tract are relatively rare congenital anomalies.
They may appear at any site along the gastrointestinal
tract, usually along the mesenteric border of the intes-
tine. Most of the cysts are jejuno-ileal. Duodenal cysts
constitute about 5% of all gastrointestinal duplica-
They have been described as causing duodenal
obstruction, pancreatitis, or may very rarely perfo-
Because they are not considered to have a direct
communication with the duodenal lumen, they were
very rarely described as a cause of gastrointestinal
A 5-month-old girl was admitted to our emergency department
because of bloody stools and hematemesis starting 4 hours before
admission. She had no prior similar complaints. She was an otherwise
normal baby except for mild failure to thrive, which was being
investigated by her pediatrician. Her perinatal history was normal; she
was born in the 40th gestational week through vaginal delivery with a
birth weight of 4.2 kg. The prenatal sonograms were likewise normal.
On admission, she was pale and apathetic. She had a pulse rate of
200 bpm, blood pressure of 80/60, and weighed 5.4 kg. There were no
abnormal ﬁndings on physical examination except for melena. A
nasogastric tube was inserted, and 200 mL of fresh blood were
aspirated. Initial blood results showed a hematocrit level of 11.6,
hemoglobin level of 3.5 gm%, white blood cell count of 13.4, and
platelets were 310,000. After a blood transfusion of 110 mL packed red
blood cells her hemoglobin level rose to 6.5 gm%, her hemodynamic
state was stabilized, and she was transferred to the operating theater.
Examination under general anesthesia showed a ﬁrm mass at the right
upper quadrant. A gastroduodenoscopy was performed and showed
blood in the ﬁrst part of the duodenum. Abdominal ultrasound scan
showed a mixed cystic-solid lesion in the right upper quadrant, adjacent
to the duodenum (Fig 1). A laparotomy was performed, and a ﬁrm 3.5-
ϫ 3- ϫ 3-cm mass was identiﬁed in close proximity to the gallbladder
and duodenum. Intraoperative cholangiogram showed a normal biliary
tract not connected to the mass. After dissection, a connection was
found between the mass and the ﬁrst part of the duodenum at its
antimesenteric border. The cyst was opened, and multiple thrombi were
found in its cavity. A 6-mm connection was identiﬁed between the cyst
and the lateral margin of the duodenum. The cyst was excised com-
pletely, and the duodenum was closed primarily. There was no evi-
dence of further active bleeding.
After the operation, the child recovered completely and was dis-
charged on the seventh postoperative day. The pathologic report
showed a ﬁbrotic tissue without epithelial lining, consistent with a
duplication cyst of the duodenum. The child is doing well 3 years after
Duplication cysts have been described by Fitz in 1884
and Ladd in 1937
and were further reﬁned by Gross in
These duplications share a common blood supply
and even a common muscular wall with the nearby
alimentary tract. The majority of the duplications are
jejuno-ileal (53%), followed by mediastinal and colonic
cysts. Duodenal duplications constitute about 5% of all
alimentary tract duplications.
The symptomatology of these cysts depends on their
type and their location. Usually, an asymptomatic mass
is found on physical or radiologic examination. Some-
times they may cause intestinal obstruction caused by
compression of adjacent structures or they may act as a
lead point for intussuception or volvulus. Peptic ulcer-
ation and perforation may result from the presence of
gastric mucosa in the cyst. Bleeding is rare and may be
painless, brisk, and life-threatening, as shown in our
From the Department of Pediatric Surgery and Radiology, Hadassah
University Medical Center, Ein-Karem, Jerusalem, Israel.
Address reprint requests to Eitan Gross, MD, Department of Pedi-
atric Surgery, Hadassah University Medical Center, PO Box 12000,
IL91120, Jerusalem, Israel.
Copyright 2002, Elsevier Science (USA). All rights reserved.
8 Journal of Pediatric Surgery, Vol 37, No 5 (May), 2002: E8