What are the guidelines for managing intestinal duplication cysts diagnosed on antenatal (before birth) ultrasound?

Management of Intestinal Duplication Cysts Diagnosed on Antenatal Ultrasound

For fetuses with intestinal duplication cysts identified on antenatal ultrasound, close monitoring with serial ultrasound examinations and planned postnatal surgical evaluation is recommended, as these lesions may cause complications including bowel obstruction, volvulus, or bleeding.

Diagnostic Evaluation

• Intestinal duplication cysts are rare congenital anomalies that can occur anywhere along the gastrointestinal tract and are characterized as anechoic, smooth, spherical or tubular structures with well-defined walls on ultrasound 1
• When identified on antenatal ultrasound, a detailed obstetrical ultrasound examination should be performed to evaluate for associated anomalies, including comprehensive fetal anatomic survey 2
• EUS (endoscopic ultrasound) can confirm the diagnosis by showing an anechoic structure with a well-defined wall that does not communicate with the gastrointestinal lumen 1
• If the cystic structure is adjacent to the pancreas, EUS/FNA may be needed to rule out pancreatic pseudocyst or pancreatic cystic neoplasm 1

Antenatal Monitoring

• Serial ultrasound examinations should be performed to monitor cyst size and characteristics 3
• Special attention should be paid to changes in cyst appearance, such as development of irregular internal echoes or debris inside the cyst, which may indicate complications 3
• A third-trimester ultrasound is recommended for reassessment and evaluation of fetal growth 2
• HDlive imaging technology can provide more realistic anatomical visualization of the cyst, making diagnosis more precise 3

Risk Assessment and Complications

• Approximately 41% of prenatally diagnosed enteric duplication cysts become symptomatic early after birth, requiring prompt surgical intervention (median 2 days of age) 4
• Larger cyst diameter is associated with higher likelihood of becoming symptomatic 4
• The anatomic distribution affects symptom likelihood - gastric duplications are more frequently asymptomatic while jejunal, proximal ileal, and colonic duplications are more frequently symptomatic 4
• Potential complications include bowel obstruction, volvulus, bleeding, and recurrent pain 4

Delivery Planning and Postnatal Management

• Pediatric providers should be informed of the antenatal finding at the time of delivery for appropriate postnatal follow-up 5
• For asymptomatic infants, close observation with planned prophylactic surgical resection in infancy (median 90 days of age) is recommended 4
• For infants who become symptomatic, prompt surgical intervention is necessary 4
• Complete surgical excision is the definitive treatment, which can be performed via laparoscopic approach even in infants as young as 8 months 6

Common Pitfalls to Avoid

• Failing to distinguish intestinal duplication cysts from other cystic abdominal masses such as ovarian cysts, mesenteric cysts, or pancreatic pseudocysts 1
• Delaying surgical intervention in symptomatic infants, which can lead to complications such as obstruction, volvulus, or bleeding 4
• Performing unnecessary invasive procedures when the diagnosis can be confirmed with non-invasive imaging 3
• Missing associated anomalies by not performing a comprehensive fetal anatomic survey 2

Special Considerations

• In adults, duplication cysts are extremely rare and often diagnosed incidentally or during surgical exploration 7, 8
• The appearance of irregular internal echoes or debris within the cyst during antenatal monitoring may indicate complications requiring closer follow-up 3
• The surgical approach (transanal, transcoccygeal, posterior sagittal, or combined abdominoperineal) depends on the anatomic characteristics of the duplication cyst 8