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398 Gastrointestinal Duplications
Ultrasonography
US is the most common modality used and should be the first choice.
It typically shows a double-layered wall (inner echogenic mucosa and
outer sonoluscent muscular layer). When this double-layered pattern
is present on US, a GID is confirmed and there is no need for further
radiologic evaluation. 25,26
Plain X-Rays
A plain chest x-ray (plain abdominal/lateral) will be able to detect fore-
gut duplications in the chest in up to 90% of cases. Plain abdominal
x-ray may show evidence of intestinal obstruction.
Figure 66.1: Spherical duplication of the ileocaecal area in an 8-month-old child.
Contrast Medium Studies
Contrast medium studies may reveal compression or displacement of
in the small and large bowels. The lining mucosa is usually the the adjacent organ. Rarely, it will show communication with the adja-
same as the adjacent normal bowel, but can be heterotopic, such as cent native organ, but it does not specify the nature of the duplication.
gastric, squamous, transitional, ciliated columnar mucosa, pancreas, CT Scan or MRI
lymphoid aggregates resembling Peyer’s patches, and ganglion cells. A CT scan or MRI is employed in difficult cases. It is noninvasive and
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Others include heterotopic lung tissue or thyroid stroma. However, has the advantage of demonstrating the exact location and relationship
heterotopic gastric and pancreatic tissues are the ones of significant to adjacent normal structures. It may also reveal other duplications. It is
clinical importance due to the risk of peptic ulceration and pancreatitis. particularly useful in thoracic, pelvic, and the rare large retroperitoneal
Even though GID in children is benign, malignant transformation has duplication cysts. A spinal MRI will outline the relationship of the cyst
been described in adults. 21
with the spinal column and spinal canal.
Diagnosis Technetium 99m Pertechnetate Scintigraphy Scan
Clinical Features This scan indicates the definite existence of GID when it contains ecto-
There is no common clinical pattern of signs and symptoms of duplica- pic gastric mucosa. This is especially useful in oesophageal, duodenal,
tions. They present with a variety of symptoms or sometimes as masses and tubular small bowel duplications with a high incidence of hetero-
found incidentally during routine examinations or investigations, or tropic gastric mucosa.
they are encountered during an operation for other problems. Laparoscopy
Most patients present before the age of 2 years, 11,12 but presentation Laparoscopy is useful in cases when all the above investigations are
during adulthood has been described. 4,22 The clinical presentation also not conclusive.
varies according to the age of the patient, location of duplication, type
of mucosal lining, duration of disease, and presence of complications. Treatment
The clinical presentation may be due to the pressure effect of the The goal is to make a prompt diagnosis and provide treatment before
duplication. Feeding difficulties are associated with masses in the floor the onset of symptoms or the development of complications. The ideal
of the mouth. In thoracic duplications, this leads to respiratory distress treatment for GID is complete excision. However, GID in children is
or dysphagia. Other symptoms in the chest include recurrent pneumonia a benign disease, and any treatment should not be more radical than to
and failure to thrive. In the abdomen, GID causes intestinal obstruction eliminate the patient’s complaints and prevent further recurrence.
but may also cause ureteric, biliary, or even vena caval obstruction. Important points to be considered in the surgical treatment of GID
Pancreatitis can arise from pressure on the pancreas. Duplications in the include:
abdomen commonly present with pain, vomiting, and abdominal mass. 1. the nature of the blood supply shared between the duplication and
The clinical presentation may also be secondary to complications native bowel;
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of the duplications. These include intussusception, volvulus, 2. the presence of heterotopic gastric mucosa, which will negate
8
23
perforation, bleeding (related to ectopic gastric mucosa), peptic internal drainage due to the risk of peptic ulceration; and
oesophageal stricture, and malignant transformation, as seen in adults. 21
3. the relationship with adjacent structures, such as the biliary tract in
Prenatal Diagnosis duodenal duplications.
Prenatal diagnosis of GIDs is becoming widespread in the Western The treatment of GID is best considered by location of the
world. This ability to accurately identify GID has provided an opportu- duplication. However, in selected cases, an intraoperative frozen
nity to intervene. In cases of nonimmune hydrops in thoracic duplica- section may give further information on the absence or presence of
tions, thoracoamniotic shunting is carried out in utero in some centres heterotopic components.
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with experience in foetal treatment. This is done in the immediate Oropharynx
postnatal period before the onset of symptoms or the development of
2
complications. Oropharyngeal duplications are rare and constitute less than 1% of
duplications. They may contain ectopic gastric or colonic mucosa.
Investigations These cysts are excised by an intraoral incision.
In the management of GID, accurate preoperative diagnosis is dif- Oesophagus
ficult. This is because GID is very rare, and the clinical presentation Oesophageal duplications are related to the right side of the oesophagus
is nonspecific. and are best approached through a right posterolateral thoracotomy.
In Africa, where resources are limited, the more expensive A supraclavicular approach is used for those located in the cervical
investigations, such as computed tomography (CT) scan and magnetic region. These lesions should be completely excised due to the high
resonance imaging (MRI), should be reserved for the very difficult incidence of gastric heterotopia in this location. Where facilities are
cases. The most common investigations carried out are ultrasonography available, a thoracoscopic approach is preferable for isolated lesions.
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(US) and contrast medium examinations.