Duplication of the Transverse Colon" Report of a Case* KULD~P TEJA, M.D., YV. T . GEISSINCER, M.D., ANTHONY SHAW, M . D .
From the Departments o[ Pathology and Surgery, University o[ Virginia Medical School, Charlottesville, Virginia
DUPLICATIONS O1: the a l i m e n t a r y canal are
well recognized d e v e l o p m e n t a l anomalies, w h i c h have b e e n described in the l i t e r a t u r e u n d e r a variety of names. "Enterocystomas,"3 "colon d u p l e x , " s " g i a n t diverticula,"7 a n d " u n u s u a l Meckel's divertic* Received for publication November 29, 1974.
u l u m ''9 are some of the e p o n y m s used b y various authors. R e l a t i v e l y f r e q u e n t sites of d u p l i c a t i o n s are the esophagus, d u o d e n um, ileum, a n d ileocecal valve, b u t they also occur at the base of t o n g u e , stomach, j e j u n u m , colon, sig-moid, a n d r e c t u m . T h e transverse c o l o n as t h e p r i m a r y site of d u p l i c a t i o n is rare. R e v i e w of r e c e n t
FIG. I. Resected specimen, revealing opened transverse colon. Duplication no. 1 is seen as a small protrusion in the lumen. Duplication no. 2 is seen as a large cyst in the transverse mesocolon. 430 Dis. Col. &Reet. J'uly-Aug. 1975
Volume 18 Number 5
Volume 18 Number S
DUPI,ICATION OF TRANSVERSE COLON
431
l i t e r a t u r e r e v e a l e d six p r e v i o u s l y d e s c r i b e d cases
of
duplication
o[
s. 6, 10-t2 T h e
present
port
separate
of
two
transverse
colon
transverse
colon.
case r e p r e s e n t s duplications
occurring
in
a
a re-
of
the
single
patient. Report
of a Case
A 9-month-old Caucasian male infant was admitted for evaluation of an asymptomatic abdominal mass discovered on routine examination. The product of a normal term delivery, he had had normal growth and development. At the age of 2 months, he had had slight rectal bleeding of bright red blood, which had subsided spontaneously. There was no other symptom referable to the gastrointestinal or genitourinary tract. Physical examination disclosed no abnormality except a firm mass, 10 cm in diameter, in the right upper quadrant, which could be displaced easily into the
FIc. 2. Diagrammatic representation of the relationship of the duplications to the transverse colon.
Flc,. 3. Both duplications shared a common muscular wall with the colon (hematoxylil~ and eosin; • 10).
4~_.9
TEJA, ET AL.
Fla. 4.
Dis. CoL & Reet. July-Aug. 1975
Duplication no. 1, showing gastric mucosal lining (hematoxylin and eosiu: • 125).
right lower and left upper quadrants. Results of laboratory investigations were normal. An intravenous pyelogram, u p p e r gastrointestinal series and barium-enema examination showed only displacement of the small bowel into t h e left lower quadrant. T h e r e was no bony abnormality of the spine. At exploration a 10-cm cystic mass was encoun-
tered in the transverse mesocolon, immediately adjacent to the bowel, and overlying the middle colic artery. Just proximal to this was a second, 4-cm, cystic mass, intimately in contact with the colonic wall. A transverse colectomy with end-toend colocolostomy was performed, followed by incidental appendectomy and Meckel's diverticulectomy.
Volume 18 iN'umber 5
433
DUPLICATION OF TRANSVERSE COLON
Fro. 5. Note the colonic mucosa in the upper part, and flattened and ulcerated epithelial lining of duplication no. 2 in the lower part (hematoxylin and eosin; • 35).
Pathology: T h e excised segment of colon was 10 cm long. A large oval cyst, 10 • 7 • 5 cm, was found in the transverse mesocolon (duplication no. 2, Fig. 1). When the cyst was opened, approximately 150 ml of whitish, thick fluid gushed out. T h e inner lining of the cyst showed a normal rugose pattern, as well as areas of flattened mucosa. Proximal to the large cyst, there was a smaller cystic lesion, 4 cm in diameter, bulging slightly in the colonic lumen through the mucosa (duplication no. 1, Fig. 1). This cyst was filled with a clear, thick mucoid secretion. No communication between the two cysts was found. The relationship of the cysts and the colon is represented diagrammatically in Figure 2. Microscopically, both cysts (duplications 1 and 2) shared a common muscular wall with the colon, at separate points of the circumference (Fig. 3). Duplication no. 1 was lined by gastric mucosa (Fig. 4). Duplication no. 2 showed a flattened and atrophic epithelium, with total loss of mucosa in large areas (Fig. 5). This was due to pressure within the cyst.
Focal areas of the lining epithelium, however, could be clearly identified as gastric mucosa. Discussion L a d d a n d G r o s s ? i n 1940, s u g g e s t e d t h r e e criteria
for d i a g n o s i n g
duplication
bowel, namely, the attachment
of t h e
or adherence
of t h e cyst to s o m e p a r t of t h e b o w e l , prese n c e of s m o o t h - m u s c l e w a l l ( u s u a l l y i n t w o layers), and an internal lining correspondi n g to s o m e p a r t of t h e a l i m e n t a r y tract. L a t e r reviews,~, 2 h o w e v e r , h a v e s h o w n t h a t m a n y s i m i l a r a n o m a l i e s d o n o t [ulfill t h e above criteria. The duplication may have a s e p a r a t e m e s e n t e r y a n d m a y lie f a r a w a y from the main bowel. Mediastinal duplications may have an epithelial
lining which
TEJA, ET AL.
434
is ciliated c o l u m n a r , or there may n o t be a n y epithelial l i n i n g of the cyst because it becomes d e n u d e d by the pressure of the encysted fluid. M u l t i p l e thoracoabdominalZ, 4 a n d a b d o m i n a l 7 d u p l i c a t i o n s have been described by various authors, b u t two duplications situated side by side are rarely encountered. I n some of the previously reported series,Z, 7 a t h i r d to half of the d u p l i c a t i o n s were l i n e d by gastric mucosa. Both duplications i n this case showed gastric mucosal l i n i n g . Ulceration, hemorrhage, a n d perforation can occur i n these duplications, especially w h e n the mucosa is of the gastric type. W e are u n a b l e to e x p l a i n this pa. t i e n t ' s episode of rectal b l e e d i n g at the age of 2 months, since no c o n n e c t i o n b e t w e e n the cysts a n d the colon was found. References I. Anderson MC, Silberman WW, Shields TW: Duplications of the alimentary tract in the adult. Arch Surg 85: 94, 1962
Dis. Col. & Rect.
yuly-Aug. 197S
2. Basu R, Forshall I, Rickham PP: Duplications of the alimentary tract. Br J Surg 47: 477, 1960 3. Dohn K, Povlsen O: Enterocystomas: Report of six cases. Acta Chir Scand 102: 21, 1951 4. Fallon M, Gordon AR, Lendrum AC: Mediastinal cysts of fore-gut origin associated with vertebral abnormalities. Br J Surg 41:520, 1954 5. Gross RE, Holcomb GW Jr, Farber S: Duplications of the alimentary tract. Pediatrics 9: 449, 1952 6. Higgins TT: A case of reduplication of the transverse colon. Br J Surg 38: 392, 1951 7. Hudson HW Jr: Giant diverticula or reduplications of the intestinal tract: Report of three cases. N Engl J Med 213: 1123, 1935 8. Judy WS Jr: Colon duplex: Case report. Northwest Med 56: 586, 1957 9. Ladd WE, Gross RE: Surgical treatment of duplications of the alimentary tract: Enterogenous cysts, enteric cysts, or ileum du. plex. Surg Gynecol Obstet 70: 295, 1940 10. Oeconomopoulos CT, Swenson O: Duplications of the gastrointestinal tract. J Pediatr 60: 361, 1962 11. Reismann B, Hern~ndez.Richter HJ, Lill G: Duplication of the transverse colon: Contribution to the development of this malformation. Z Kinderchir 10: 184, 1971 12. Sulamaa M, Nyberg LO: On duplications of the alimentary tract (two cases). Acta Chir Scand 98: 171, 1949
From the Departments o[ Pathology and Surgery, University o[ Virginia Medical School, Charlottesville, Virginia
DUPLICATIONS O1: the a l i m e n t a r y canal are
well recognized d e v e l o p m e n t a l anomalies, w h i c h have b e e n described in the l i t e r a t u r e u n d e r a variety of names. "Enterocystomas,"3 "colon d u p l e x , " s " g i a n t diverticula,"7 a n d " u n u s u a l Meckel's divertic* Received for publication November 29, 1974.
u l u m ''9 are some of the e p o n y m s used b y various authors. R e l a t i v e l y f r e q u e n t sites of d u p l i c a t i o n s are the esophagus, d u o d e n um, ileum, a n d ileocecal valve, b u t they also occur at the base of t o n g u e , stomach, j e j u n u m , colon, sig-moid, a n d r e c t u m . T h e transverse c o l o n as t h e p r i m a r y site of d u p l i c a t i o n is rare. R e v i e w of r e c e n t
FIG. I. Resected specimen, revealing opened transverse colon. Duplication no. 1 is seen as a small protrusion in the lumen. Duplication no. 2 is seen as a large cyst in the transverse mesocolon. 430 Dis. Col. &Reet. J'uly-Aug. 1975
Volume 18 Number 5
Volume 18 Number S
DUPI,ICATION OF TRANSVERSE COLON
431
l i t e r a t u r e r e v e a l e d six p r e v i o u s l y d e s c r i b e d cases
of
duplication
o[
s. 6, 10-t2 T h e
present
port
separate
of
two
transverse
colon
transverse
colon.
case r e p r e s e n t s duplications
occurring
in
a
a re-
of
the
single
patient. Report
of a Case
A 9-month-old Caucasian male infant was admitted for evaluation of an asymptomatic abdominal mass discovered on routine examination. The product of a normal term delivery, he had had normal growth and development. At the age of 2 months, he had had slight rectal bleeding of bright red blood, which had subsided spontaneously. There was no other symptom referable to the gastrointestinal or genitourinary tract. Physical examination disclosed no abnormality except a firm mass, 10 cm in diameter, in the right upper quadrant, which could be displaced easily into the
FIc. 2. Diagrammatic representation of the relationship of the duplications to the transverse colon.
Flc,. 3. Both duplications shared a common muscular wall with the colon (hematoxylil~ and eosin; • 10).
4~_.9
TEJA, ET AL.
Fla. 4.
Dis. CoL & Reet. July-Aug. 1975
Duplication no. 1, showing gastric mucosal lining (hematoxylin and eosiu: • 125).
right lower and left upper quadrants. Results of laboratory investigations were normal. An intravenous pyelogram, u p p e r gastrointestinal series and barium-enema examination showed only displacement of the small bowel into t h e left lower quadrant. T h e r e was no bony abnormality of the spine. At exploration a 10-cm cystic mass was encoun-
tered in the transverse mesocolon, immediately adjacent to the bowel, and overlying the middle colic artery. Just proximal to this was a second, 4-cm, cystic mass, intimately in contact with the colonic wall. A transverse colectomy with end-toend colocolostomy was performed, followed by incidental appendectomy and Meckel's diverticulectomy.
Volume 18 iN'umber 5
433
DUPLICATION OF TRANSVERSE COLON
Fro. 5. Note the colonic mucosa in the upper part, and flattened and ulcerated epithelial lining of duplication no. 2 in the lower part (hematoxylin and eosin; • 35).
Pathology: T h e excised segment of colon was 10 cm long. A large oval cyst, 10 • 7 • 5 cm, was found in the transverse mesocolon (duplication no. 2, Fig. 1). When the cyst was opened, approximately 150 ml of whitish, thick fluid gushed out. T h e inner lining of the cyst showed a normal rugose pattern, as well as areas of flattened mucosa. Proximal to the large cyst, there was a smaller cystic lesion, 4 cm in diameter, bulging slightly in the colonic lumen through the mucosa (duplication no. 1, Fig. 1). This cyst was filled with a clear, thick mucoid secretion. No communication between the two cysts was found. The relationship of the cysts and the colon is represented diagrammatically in Figure 2. Microscopically, both cysts (duplications 1 and 2) shared a common muscular wall with the colon, at separate points of the circumference (Fig. 3). Duplication no. 1 was lined by gastric mucosa (Fig. 4). Duplication no. 2 showed a flattened and atrophic epithelium, with total loss of mucosa in large areas (Fig. 5). This was due to pressure within the cyst.
Focal areas of the lining epithelium, however, could be clearly identified as gastric mucosa. Discussion L a d d a n d G r o s s ? i n 1940, s u g g e s t e d t h r e e criteria
for d i a g n o s i n g
duplication
bowel, namely, the attachment
of t h e
or adherence
of t h e cyst to s o m e p a r t of t h e b o w e l , prese n c e of s m o o t h - m u s c l e w a l l ( u s u a l l y i n t w o layers), and an internal lining correspondi n g to s o m e p a r t of t h e a l i m e n t a r y tract. L a t e r reviews,~, 2 h o w e v e r , h a v e s h o w n t h a t m a n y s i m i l a r a n o m a l i e s d o n o t [ulfill t h e above criteria. The duplication may have a s e p a r a t e m e s e n t e r y a n d m a y lie f a r a w a y from the main bowel. Mediastinal duplications may have an epithelial
lining which
TEJA, ET AL.
434
is ciliated c o l u m n a r , or there may n o t be a n y epithelial l i n i n g of the cyst because it becomes d e n u d e d by the pressure of the encysted fluid. M u l t i p l e thoracoabdominalZ, 4 a n d a b d o m i n a l 7 d u p l i c a t i o n s have been described by various authors, b u t two duplications situated side by side are rarely encountered. I n some of the previously reported series,Z, 7 a t h i r d to half of the d u p l i c a t i o n s were l i n e d by gastric mucosa. Both duplications i n this case showed gastric mucosal l i n i n g . Ulceration, hemorrhage, a n d perforation can occur i n these duplications, especially w h e n the mucosa is of the gastric type. W e are u n a b l e to e x p l a i n this pa. t i e n t ' s episode of rectal b l e e d i n g at the age of 2 months, since no c o n n e c t i o n b e t w e e n the cysts a n d the colon was found. References I. Anderson MC, Silberman WW, Shields TW: Duplications of the alimentary tract in the adult. Arch Surg 85: 94, 1962
Dis. Col. & Rect.
yuly-Aug. 197S
2. Basu R, Forshall I, Rickham PP: Duplications of the alimentary tract. Br J Surg 47: 477, 1960 3. Dohn K, Povlsen O: Enterocystomas: Report of six cases. Acta Chir Scand 102: 21, 1951 4. Fallon M, Gordon AR, Lendrum AC: Mediastinal cysts of fore-gut origin associated with vertebral abnormalities. Br J Surg 41:520, 1954 5. Gross RE, Holcomb GW Jr, Farber S: Duplications of the alimentary tract. Pediatrics 9: 449, 1952 6. Higgins TT: A case of reduplication of the transverse colon. Br J Surg 38: 392, 1951 7. Hudson HW Jr: Giant diverticula or reduplications of the intestinal tract: Report of three cases. N Engl J Med 213: 1123, 1935 8. Judy WS Jr: Colon duplex: Case report. Northwest Med 56: 586, 1957 9. Ladd WE, Gross RE: Surgical treatment of duplications of the alimentary tract: Enterogenous cysts, enteric cysts, or ileum du. plex. Surg Gynecol Obstet 70: 295, 1940 10. Oeconomopoulos CT, Swenson O: Duplications of the gastrointestinal tract. J Pediatr 60: 361, 1962 11. Reismann B, Hern~ndez.Richter HJ, Lill G: Duplication of the transverse colon: Contribution to the development of this malformation. Z Kinderchir 10: 184, 1971 12. Sulamaa M, Nyberg LO: On duplications of the alimentary tract (two cases). Acta Chir Scand 98: 171, 1949
