We present the case of a 30-years-old man, with history of gastroesophageal reflux who was previously submitted to Nissen fundoplication. He underwent an esophageal barium videofluoroscopy which revealed ﬁlling defect in the lower third of the esophagus (Figure 1).
Figure 1: Barium swallow – Filling defect in the lower third of the esophagus.
It led to possibility of a mass lesion in the distal thoracic esophagus. For additional assessment, a contrast-enhanced computed tomography of thorax was performed and it revealed in the distal esophagus an oval cystic lesion measuring 3.5×4.0 cm (Figure 2).
Figure 2: Axial computed tomography of the chest – Cystic lesion.
For diagnostic confirmation, we performed an endoscopic ultrasound (EUS). EUS showed an anechoic and homogenous lesion, with 41×31 mm and regular margins arising from muscularis propria layer, between 41 and 36 cm from the dental arch. The cystic lesion did not communicate with the esophageal lumen and it was independent from surrounding structures (Figure 3).
Figure 3: Endoscopic ultrasound – Duplication cyst.
Based on these findings we assume the diagnosis of an esophageal duplication cyst. EUS-FNA was not performed due to characteristic imaging findings and significant risk of infection associated with the procedure.
Gastrointestinal tract duplication cysts are rare congenital gastrointestinal malformations. The esophagus is the second most common site for gastrointestinal duplication cysts after the jejunum and ileum and represents around 10-15% of all cases.1-2 Esophageal duplication cysts are thought to arise from abnormal budding of the embryonic foregut at 5-8 weeks gestation, although the exact embryonic origin of different types of duplication cysts remains a mystery. EUS is the most appropriate diagnostic tool to investigate duplication cysts since it can distinguish between solid and cystic lesions and can establish the cyst location relative to surrounding tissues.3
1. Novellis P, Graffeo M, Sparano L, et al. Endoultrasonography (EUS) examination of the esophagus in the diagnosis of esophageal duplication: a case report and a review of a literature. Eur Rev Med Pharmacol Sci 2015;19(16):3041–5.
2. Liu R, Adler DG. Duplication cysts: Diagnosis, management, and the role of endoscopic ultrasound. Endosc ultrasound 2014;3(3):152–60.
3. Al-Riyami S, Al-Sawafi Y. True Intramural Esophageal Duplication Cyst. Oman Med J 2015;30(6):469–72.
Liliane Meireles1, Sandra Faias2, A. Dias Pereira2
1. Serviço de Gastrenterologia e Hepatologia do Centro Hospitalar de Lisboa Norte, EPE.
2. Serviço de Gastrenterologia do IPO de Lisboa.