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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 54  |  Issue : 1  |  Page : 32-35

Intestinal duplication in an elderly-male presented as sigmoid volvulus


Department of Surgery, GSL Medical College, Rajahmundry, Andhra Pradesh, India

Date of Submission02-May-2020
Date of Decision26-May-2020
Date of Acceptance01-Sep-2020
Date of Web Publication22-Jan-2021

Correspondence Address:
Samir Ranjan Nayak
Department of Surgery, GSL Medical College, Rajahmundry - 533 296, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_60_20

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  Abstract 


Alimentary tract duplications are uncommon congenital anomalies that are often detected in the first decade of life. However, a smaller number of cases may remain unsuspected until adulthood. These anomalies are most common in the ileum and usually present at the bowel's mesenteric border. These can also occur anywhere in the digestive tract. This article reports a case of a 74-year-old male with intestinal duplication arising from the antimesenteric border of the transverse colon, who clinically presented as sigmoid volvulus.

Keywords: Antimesenteric border, colon, intestinal duplication


How to cite this article:
Reddy V, Eemaraka N, Jasmine YJ, Nayak SR. Intestinal duplication in an elderly-male presented as sigmoid volvulus. Formos J Surg 2021;54:32-5

How to cite this URL:
Reddy V, Eemaraka N, Jasmine YJ, Nayak SR. Intestinal duplication in an elderly-male presented as sigmoid volvulus. Formos J Surg [serial online] 2021 [cited 2021 Mar 8];54:32-5. Available from: https://www.e-fjs.org/text.asp?2021/54/1/32/307623




  Introduction Top


Alimentary tract duplications (ATD) are rare congenital anomalies that may occur anywhere in the intestinal tract, from the mouth to the anus.[1] They are often found early in life. A small number of cases may remain undiscovered until adulthood, when they may give rise to different symptoms, depending on the location.[2] Intestinal duplication occurs in 33% of cases in the foregut. About 56% of cases are observed in the midgut with ileal duplication, whereas 11% of cases are observed in the hindgut.[3] Duplications of the colon are less common, accounting for 4%–18% of all gastrointestinal (GI) duplications.[4] ATD is usually diagnosed in children before the age of 2 years. Due to the rarity of ATD and its significant relevance in the pediatric population, the analyses of patient characteristics and clinical manifestations in the adult are limited.[2] The clinical presentation of intestinal duplication in adults is usually asymptomatic but may result in significant morbidity and mortality. Diagnosis of intestinal duplication may be difficult due to the inability of the standard endoscopic investigation to visualize these anomalies. Therefore, radiographic studies such as barium meal or enema study, ultrasonography, and computed tomography (CT) scan play an essential role in establishing the correct diagnosis and providing guidance in its appropriate management.[2] Diagnosis in adults is challenging for the clinician in case intestinal duplication is presented with complications such as perforation, volvulus, or intestinal obstruction.[2],[3]

In this report, we describe a case of intestinal duplication arising from the antimesenteric border of the transverse colon that presented as volvulus of the sigmoid colon.


  Case Report Top


A 74-year-old male was brought to the emergency to the emergency department with complaints of abdominal distension, abdominal pain, vomiting, and constipation for the past 3 days. His medical and family histories were unremarkable. On clinical examination, the patient looked sick and febrile with a temperature of 37.7°C, a pulse rate of 120 beats/minute, and a respiratory rate of 30 breaths/minute. On physical examination, the abdomen was grossly distended with diffuse tenderness over all quadrants. Rigidity and guarding were absent, and no mass was palpable. The liver dullness was not obliterated, and bowel sounds were absent. Digital rectal examination was found to be negative for any mass or blood. After initial fluid resuscitation, the patient was subjected to further investigations. Laboratory data revealed elevated total leukocyte count at 16 × 109 cells/L with 86% neutrophil. Renal and liver parameters were within the normal limit.

Abdominal ultrasonogram revealed grossly dilated bowel loops with sluggish peristalsis. The plain X-ray of the abdomen showed [Figure 1] a dilated large bowel and a loaded colonic shadow visualized at the left flank. Subsequently, the patient was diagnosed with sigmoid volvulus. We performed exploratory laparotomy with due consent.
Figure 1: Plain X-ray of the abdomen- dilated large bowel, another dilated loop filled with fecal matter at the left flank

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On exploration, we noticed enormous dilatation of the sigmoid colon with another long tubular blind intestinal loop of around 30 cm lying on the left flank left to the descending colon. The intestine's loaded loop emerged from the antimesenteric border of the transverse colon [Figure 2]. The end of the blind loop formed an inflammatory adhesion at the distal part of the sigmoid colon. This caused proximal bowel dilatation that mimicked sigmoid volvulus. The blind intestinal loop was tubular, originating at the mid transverse colon [Figure 3]. We performed left hemicolectomy with colo-colic anastomosis. In the postoperative period, the patient was kept on a mechanical ventilator for 24 h, and he subsequently recovered. The patient was given oral liquids from the 4th postoperative day and a soft diet from the 6th day post operation. Macroscopic examination showed a tubular structure arising from the antimesenteric border of the colon, measuring 20 cm × 2.5 cm × 2 cm. The duplicated bowel loop was communicated with the normal colonic lumen. Light microscopy highlighted the four-layered digestive tract wall. It included a mucosa with an intestinal-type epithelial lining and a muscularis propria. The structure of muscularis propria consisted of an inner circular and outer longitudinal smooth muscle layers.
Figure 2: Duplicated intestine situated left to the descending colon mobilized

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Figure 3: Resected specimen- intestinal duplication arising from the transverse colon

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  Discussion Top


Enteric duplications are rare congenital anomalies found along with the GI tract, from the mouth to the rectum. About 75% of duplications have been reported to be located within the abdominal cavity, whereas the remaining is intrathoracic (20%) or thoracoabdominal (5%). Ileal duplications are the most common (53%), followed by mediastinal (18%), colonic (13%), gastric (7%), duodenal (6%), rectal (4%), esophageal (2%), and cervical (1%) lesions.[5]

Several theories have been proposed to explain the etiology of ATD. The four major theories for the formation of ATD are partial twinning theory, split notochord theory, canalization defects theory, and environmental factors theory. The aberrant luminal canalization defects theory is based on the process by which all GI organs begin as solid organs in the embryologic state gradually vacuolate to form the lumen. During this process, multiple diverticula form in the fetal stage, which regresses with development. Many postulate that this may be the most common explanation for enteric duplication.[6]

The duplicated intestine characteristically arises from the mesenteric border of the bowel.[2],[7] It often continues along the regular bowel wall and shares the muscle and mucosal layer.[8] Moreover, intestinal duplication is characterized by well-developed smooth muscles, which is absent in intestinal diverticula. The uniqueness in our case was the presence of the duplicated tubular loop that emerged from the antimesenteric border of the transverse colon. The first case of an intestinal duplication cyst appearing on the antimesenteric intestinal border has been reported in literature.[9] Our presented case may be the second case in literature.

Clinical presentation of ATD is variable and depends on the structure, size, and site of the lesion concerning the surrounding structure. ATD presentation includes recurrent abdominal pain, vomiting, abdominal distension, GI bleeding, and peritonitis. The latter presentation is due to peptic ulcer perforation occurring in the duplicated segment with ectopic gastric mucosa or the adjacent healthy bowel. This duplication can result in intussusception.[10] Most of the adult intestinal duplications may remain asymptomatic and may present as abdominal pain, rectal bleeding, constipation, or acute bowel obstruction in some cases.

Multiple diagnostic tools, including abdominal ultrasonography, GI endoscopy, and contrast-enhanced CT scan, have been used to investigate intestinal duplication in adults. Ultrasonography and contrast-medium examinations are the most commonly used investigate tools to detect ATD. However, CT scans and magnetic resonance imaging can be helpful in complicated cases that require a multiplanar approach.[11]

Resection by surgery is the preferred method of treatment for most GI duplications. The treatment of choice for enteric duplication is complete surgical excision, even if it is found incidentally. Adjacent normal bowel wall needs to be resected due to potential complications such as malignant changes, ulceration, and bleeding.[12] A previous study reported a case of colonic duplication cyst manifesting in the acute abdomen and intussusception. This necessitates a right-sided hemicolectomy.[13] However, the surgical decision depends on multiple factors such as location, type, and relationship with the surrounding tissue.


  Conclusion Top


Diagnosing intestinal duplication in adults is difficult due to the rarity of the condition. Because its symptoms are not specific, ATD is not considered in the differential diagnosis for acute abdomen. To the best of knowledge, our report of duplicated intestine situated at the antimesenteric border of the colon is the second case reported in literature. Surgical excision is the treatment of choice in ATD, and resection of the entire duplication should be undertaken in adults to avoid reported incidences of malignancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ashcraft KW, Holcomb III GW, Murphy JP. Pediatric Surgery. 4th ed. Ch. 39. Philadelphia: Elsevier Saunders; 2005. p. 543-52.  Back to cited text no. 1
    
2.
Fiorani C, Scaramuzzo R, Lazzaro A, Biancone L, Palmieri G, Caspari AL, et al. Intestinal duplication in adulthood: a rare entity, difficult to diagnose. World J Gastrointest Surg 2011;3:128-30.  Back to cited text no. 2
    
3.
Shah A, Du J, Sun Y, Cao D. Dynamic change of intestinal duplication in an adult patient: A case report and literature review. Case Rep Med 2012;2012:297585.  Back to cited text no. 3
    
4.
Bissler JJ, Klein RL. Alimentary tract duplications in children: Case and literature review. Clin Pediatr (Phila) 1988;27:152-7.  Back to cited text no. 4
    
5.
Sharma S, Yadav AK, Mandal AK, Zaheer S, Yadav DK, Samie A. Enteric duplication cysts in children: A clinicopathological dilemma. J Clin Diagn Res 2015;9:EC08-11.  Back to cited text no. 5
    
6.
Stern LE, Warner BW. Gastrointestinal duplications. Semin Pediatr Surg 2000;9:135-40.  Back to cited text no. 6
    
7.
Keramidas DC, Demetriades DM. Total tubular duplication of the colon and distal ileum combined with transmesenteric hernia: Surgical management and long-term-results. Eur J Pediatr Surg 1996;6:243-4.  Back to cited text no. 7
    
8.
Sinha A, Ojha S, Sarin YK. Completely isolated, noncontiguous duplication cyst. Eur J Pediatr Surg 2006;16:127-96.  Back to cited text no. 8
    
9.
Sfoungaris D, Magdalini M, Patoulias I, Panteli C, Valioulis I. Antimesenteric gastrointestinal tract duplication undergoing non-ulcerative perforation. Rom J Morphol Embryol 2018;59:1275-8.  Back to cited text no. 9
    
10.
Lee NK, Kim S, Jeon TY, Kim HS, Kim DH, Seo HI, et al. Complications of congenital and developmental abnormalities of the gastrointestinal tract in adolescents and adults: Evaluation with multimodality imaging. Radiographics 2010;30:1489-507.  Back to cited text no. 10
    
11.
Hur J, Yoon CS, Kim MJ, Kim OH. Imaging features of gastrointestinal tract duplications in infants and children: From oesophagus to rectum. Pediatr Radiol 2007;37:691-9.  Back to cited text no. 11
    
12.
Puligandla PS, Nguyen LT, St-Vil D, Flageole H, Bensoussan AL, Nguyen VH, et al. Gastrointestinal duplications. J Pediatr Surg 2003;38:740-4.  Back to cited text no. 12
    
13.
Reiser-Erkan C, Erkan M, Ulbrich E, Nährig J, Kleeff J. Cystic colon duplication causing intussusception in a 25-year-old man: Report of a case and review of the literature. BMC Surg 2010;10:19.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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