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AFIP ARCHIVES

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Best Cases from the AFIP
Ileocecal Enteric Duplication Cyst: Radiologic-Pathologic Correlation1
Editor’s Note.—Everyone who has taken the course in radiologic pathology at the Armed Forces Institute of Pathology (AFIP) remembers bringing two beautifully illustrated cases for accession to the Institute. In recent years, the staff of the Department ofRadiologic Pathology has judged the “best cases” by organ system, and recognition is given to the winners on the last day of the class. With each issue of RadioGraphics, one of these cases is published, written by the winning resident. Radiologic-pathologic correlation is emphasized, and the causes of the imaging signs of various diseases are illustrated.

Samuel C. Tong, MD ● Martha Pitman, MD ●Sudha A. Anupindi, MD History
A 13-year-old boy with no medical or surgical history presented to the emergency room with acute abdominal pain followed by multiple episodes of vomiting. He had recently eaten some uncooked cookie dough but nothing else for the day. His vital signs were normal, and he was afebrile. The patient’s abdomen was soft, flat, and nontender with good bowel sounds and nomasses. The white blood cell count was 12,800/ L (normal range, 4.5–13.5 103/ L). Appendicitis was suspected.

Imaging Findings
Initially, pelvic computed tomography (CT) with only rectal contrast material was performed. There was a large, well-circumscribed, low-attenuation, lobulated mass within the cecum (Fig 1). The distal small intestine was mildly dilated and filled with fluid. A normal appendixwas identified, and the diagnosis of appendicitis was excluded. Abdominal CT with intravenous and oral contrast material followed. It demonstrated a lobulated, tubular mass that measured approximately 9 cm in the anterior-posterior dimension and approximately 3 cm in the transverse dimension. The mass extended into the cecum and ascending colon (Fig 2a). The mass demonstrated peripheralenhancement and uniform central low attenuation of 30 HU. The mass was now dumbbell-shaped (Fig 2a), in contrast to the lobulated appearance in the prior pelvic CT study. The distal ileum was mildly dilated.

Index terms: Intestines, abnormalities, 742.141, 752.141 ● Intestines, cysts, 742.141, 752.141 RadioGraphics 2002; 22:1217–1222
1From

the Departments of Radiology (S.C.T., S.A.A.) and Pathology(M.P.), Massachusetts General Hospital, 34 Fruit St, White 246, Boston, MA 02114. Received March 1, 2002; revision requested March 27 and received May 6; accepted May 6. Address correspondence to S.A.A. (e-mail: sanupindi@partners.org). RSNA, 2002

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Figures 1, 2. (1) CT scan obtained with rectallyadministered contrast material shows a lobulated, lowattenuation, well-circumscribed filling defect (arrows) in the cecum. (2a) CT scan shows a homogeneous, dumbbell-shaped mass with thin, uniform rim enhancement (arrows) that extends into the cecum near the region of the ileocecal valve. (2b) CT scan shows the changing shape of the lesion (arrows). The attenuation value in the central part of the lesion (30HU) indicates that it is a cyst.

The abdominal CT study was immediately followed by a single-contrast barium enema study. It showed a large mass within the cecum. The mucosal surface was normal, suggesting a submucosal origin (Fig 3a). This mass corresponded to the lesion seen in the abdominal and pelvic CT studies. There was reflux of contrast material into a normal terminal ileum. The mass wasmalleable and mobile and changed shape with compression (Fig 3b, 3c). A normal appendix excluded the diagnosis of appendicitis, and reflux of contrast material into a normal terminal ileum excluded the diagnosis of ileocolic intussusception or obstruction.

The peripheral rim enhancement, lack of central enhancement, and malleability of the lesion were consistent with a cystic rather than a...