A 50 year old male with chief complaint of post-prandial vague abdominal pain had a capsule endoscopy exam, which showed submucosal mass in the proximal small bowel. Upper endoscopy showed a 2 cm submucosal bulge in the third portion of the duodenum occupying 1/4th of the lumen with normal overlying mucosa. This lesion was soft and collapsed somewhat when probed with a closed biopsy forceps. Endoscopic ultrasound (EUS) examination done with 12mHz miniprobe showed anechoic homogenous cyst in the submucosa measuring 16 mm x 14 mm in size with normal overlying mucosa, deep mucosa and normal underlying muscularis propria. These images again show the soft compressible lesion in the duodenum. Upon biopsy a cloudy, milky fluid was seen coming out of the submucosal bulge resulting in the decompression of the lesion. The EUS examination and endoscopic examination findings were consistent with duplication cyst. Patient reported improvement in his symptoms after this endoscopic intervention.
Duplication cysts are benign, rare anomalies that arise during early embryonic development. They are most frequently found in the proximal small intestine. Typical endosonographic appearance of anechoic homogenous lesion in the submucosal layer of the gastrointestinal wall is consistent with duplication cyst.
Cloudy, milky fluid can also be seen in the lymphangiomas. The most common location for the lymphangiomas is in the esophagus. On the upper endoscopy lymphangioma usually appear as translucent, yellowish, easily compressible mass that is usually less than 5 mm in size. Diagnosis can be suggested on the EUS exam showing a solid lesion located in the submucosal layer of the gastrointestinal wall.
Harry Aslanian, M.D., Yale University
Manmeet Padda, MD, Yale University