J Korean Med Sci 2004; 19: 604-7 ISSN 1011-8934 Copyright The Korean Academy of Medical Sciences Duodenal Duplicated Cyst Manifested by Acute Pancreatitis and Obstructive Jaundice in an Elderly Man A duodenal duplication cyst is an uncommon congenital anomaly that is usually encountered during infancy or in early childhood. Duodenal duplication cysts gen- erally appear on the first or second portion of the duodenum and may cause duo- denal obstruction, hemorrhage or pancreatitis. Here, we report a case of a duode- nal duplication cyst on the second and third portion of the duodenum in an old aged man with obstructive jaundice and acute pancreatitis, which was treated suc- cessfully by a surgical excision. Key Words : Abnormalities; Duplication Cyst; Duodenum; Pancreatitis, Acute Necrotizing; Jaundice, Obstruc- tive INTRODUCTION Duodenal duplication cyst (DDC) is a rare congenital ano- maly (1-13), which can appear during the neonatal period or later in life depending on the degree of the gastric outlet obstruction. About thirty percent of patients diagnosed with duplication cysts are older than twelve years of age, and the oldest patient with DDCs reported was 73 yr old (1). These lesions often present a diagnostic and therapeutic challenge to surgeons. Duplications of the duodenum may be either cystic or tubular and are composed of a muscular wall with a gastrointestinal epithelial lining. Duplication cysts may be found at any level from the mouth to the anus and are usu- ally attached intimately to some portions of the gastrointesti- nal tract. Only 4-12% of these duplications are located in the duodenum. Here, we describe the first Korean case of a DDC associated with bowel obstruction, obstructive jaun- dice and acute pancreatitis in the later period of life. CASE REPORT A 65-yr-old man was referred to our hospital complaining of pain in the right upper quadrant and vomiting for previous 3 days. His past medical history was unremarkable except for a spinal operation performed due to a falling-down injury 10 yr ago. A physical examination demonstrated tenderness 604 and a soft palpable mass on the right upper quadrant of the abdomen. The laboratory examinations showed a hemoglobin level of 15.3 g/dL (normal range, 14 to 18), a white blood cell count of 12,590/ L (normal range, 4,000 to 10,000), and a platelet count of 254,000/ L (normal range, 140,000 to 400,000). The liver function tests showed a total serum biliru- bin level of 3.3 mg/dL (normal range, 0.1 to 1.2), a direct bilirubin level of 2.1 mg/dL (normal range, 0.1 to 0.4), alka- line phosphatase level of 323 IU/L (normal range, 20 to 90), a gamma glutamyl transpeptidase level of 371 IU/L (normal range, 0 to 50), an aspartate aminotransferase level of 267 IU/L (normal range, 10 to 35); alanine aminotransferase, 228 IU/L (normal range, 0 to 40); amylase, 972 IU/L (normal range, 50 to 160) and a lipase level of 2,767 IU/L (normal range, 0 to 200). A duodenoscopy revealed a huge extrinsic mass with an intact mucosa causing almost complete lumi- nal obstruction in the second portion of the duodenum. On palpation with a biopsy forcep, the mass was found to be soft and easily compressible (Fig. 1). A computerized tomography scan showed a 12×6 cm sized elliptic cystic lesion with a distinct wall at the second-to-third portion of the duodenum. The lesion occupied the intramural portion of the duodenal wall. These findings above were consistent with a DDC (Fig. 2). The intrahepatic duct and common bile duct were dilat- ed, and the gallbladder was markedly distended (Fig. 3). A percutaneous transhepatic biliary drainage for the relief of obstructive jaundice was performed one day after admission. Young Chul Jo, Kwang Ro Joo*, Do Ha Kim, Jong Ho Park, Jae Hee Suh , Young Min Kim , Chang Woo Nam Departments of Internal Medicine, Pathology and Surgery , Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan; Department of Internal Medicine, Kyung Hee University College of Medicine*, Seoul, Korea Received : 24 July 2003 Accepted : 1 September 2003 Address for correspondence Kwang Ro Joo, M.D. Department of Internal Medicine, Kyung Hee University College of Medicine, 1 Hoigi-dong, Dongdaemoon-gu, Seoul 130-702, Korea Tel : +82.2-958-8099, Fax : +82.2-968-1848 E-mail : gicolon@unitel.co.kr