Gastric outlet obstruction caused by heterotopic pancreas in an adolescent

Gastric outlet obstruction caused by heterotopic pancreas in a patient with alcohol use disorder

INTRODUCTION AND IMPORTANCE

Heterotopic Pancreas (HP) is defined by the presence of pancreatic tissue in an anatomically distinct location from the main pancreas. While often clinically silent, it may present symptomatically. If located in the gastric antrum, HP may cause gastric outlet obstruction (GOO). The objective of this paper is to present a rare case of HP in the gastric antrum causing GOO.

CASE PRESENTATION

Herein, we report a 43-year-old man who presented with abdominal pain and non-bilious emesis in the setting of COVID-19 infection and alcohol consumption. During the initial workup, computed-tomography (CT) was non-specific but demonstrated GOO, concerning for cancer. Cold forceps biopsies taken during esophagogastroduodenoscopy (EGD) confirmed benign HP. Since the patient was symptomatic from gastric outlet compression, he underwent resection via laparoscopic distal gastrectomy and Billroth II gastrojejunostomy. At 1-month postoperative follow-up, the patient recovered uneventfully. We hypothesized that GOO by HP in this case may have been associated with cumulative effects of alcohol consumption and COVID-19 infection on the ectopic tissue.

CLINICAL DISCUSSION

HP is rare and difficult to diagnose preoperatively. When located in gastric antrum, HP can cause GOO, mimicking gastric malignancy. Combination of EGD/EUS, biopsy/FNA, and surgical resection are necessary to definitively make the diagnosis. Finally, it is important to consider that heterotopic pancreatitis or structural changes in HP may occur due to classic pancreatic stressors like alcohol and viral infections.

CONCLUSION

HP may cause GOO presenting with non-bilious emesis and abdominal pain, mistaken for malignancy on CT imaging.

Pancreatic pseudocyst as a cause for gastric outlet obstruction

The pancreatic pseudocyst contains pancreatic enzymes encapsulated by a non-epithelialized wall. They are rare in the pediatric population and are mostly a result of pancreatic trauma: extrinsic, or intrinsic. Management options include conservative or surgical, depending on the clinical signs and symptoms, and the size of the cyst.

Clinical classification of symptomatic heterotopic pancreas of the stomach and duodenum: A case series and systematic literature review

BACKGROUND

Heterotopic pancreas (HP) is an aberrant anatomic malformation that occurs most commonly in the upper gastrointestinal tract. While the majority of heterotopic pancreatic lesions are asymptomatic, many manifest severe clinical symptoms which require surgical or endoscopic intervention. Understanding of the clinical manifestations and symptoms of HP is limited due to the lack of large volume studies in the literature. The purpose of this study is to review symptomatic cases at a single center and compare these to a systematic review of the literature in order to characterize common clinical manifestations and treatment of this disease.

AIM

To classify the common clinical manifestations of heterotopic pancreas.

METHODS

A retrospective review was conducted of pathologic samples containing heterotopic pancreas from 2000-2018. Review was limited to HP of the upper gastrointestinal tract due to the frequency of presentation in this location. Symptomatic patients were identified from review of the medical records and clinical symptoms were tabulated. These were compared to a systematic review of the literature utilizing PubMed and Embase searches for papers pertaining to heterotopic pancreas. Publications describing symptomatic presentation of HP were selected for review. Information including demographics, symptoms, presentation and treatment were compiled and analyzed.

RESULTS

Twenty-nine patient were identified with HP at a single center, with six of these identified has having clinical symptoms. Clinical manifestations included, gastrointestinal bleeding, gastric ulceration with/without perforation, pancreatitis, and gastric outlet obstruction. Systemic review of the literature yielded 232 publications detailing symptomatic cases with only 20 studies describing ten or more patients. Single and multi-patient studies were combined to form a cohort of 934 symptomatic patients. The majority of patients presented with abdominal pain (67%) combined with one of the following clinical categories: (1) Dyspepsia, (n = 445, 48%); (2) Pancreatitis (n = 260, 28%); (3) Gastrointestinal bleeding (n = 80, 9%); and (4) Gastric outlet obstruction (n = 80, 9%). The majority of cases (n = 832, 90%) underwent surgical or endoscopic resection with 85% reporting resolution or improvement in their symptoms.

CONCLUSION

Heterotopic pancreas can cause significant clinical symptoms in the upper gastrointestinal tract. Better understanding and classification of this disease may result in more accurate identification and treatment of this malformation.

Unusual Tissue - Unusual Issue: Pancreatic Heterotopia Presenting as Gastric Outlet Obstruction

Pancreatic heterotopia (PH) is a common, but typically small (<1 cm), incidental and asymptomatic finding; however, PH should be considered even for large and symptomatic upper gastrointestinal masses. A 27-year-old white woman presented with a 3-week history of burning epigastric pain, nausea, early satiety, and constipation. Physical examination revealed epigastric and right upper quadrant tenderness with normal laboratory workup, but imaging revealed a 5-cm, partly cystic mass arising from the gastric antrum with resulting pyloric stenosis and partial gastric outlet obstruction. Endoscopic ultrasound-guided fine needle aspiration revealed PH − an anomalous pancreatic tissue lying in a nonphysiological site. The patient ultimately underwent a resection and recovered uneventfully, with a complete pathologic examination revealing normal exocrine pancreatic tissue (PH type 2) without malignant transformation. We report a case of heterotopic pancreas manifesting as severe gastric outlet obstruction, in addition to a thorough diagnostic workup and surgical follow-up, in a young adult. Differential diagnoses and features that speak to benignity of a large, symptomatic mass lesion (PH in particular) are discussed.

Gastric heterotopic pancreas in children: A prospective endoscopic study

PURPOSE

To document the prevalence and variable appearance of gastric heterotopic pancreas (HP) in children undergoing upper gastrointestinal (GI) endoscopy.

METHODS

A prospective 4-year study of children undergoing flexible upper GI endoscopy in a single institution.

RESULTS

A total of 607 upper GI endoscopies were performed in 478 pediatric patients during the 4-year period. Eleven children (6 girls, 5 boys) aged 2.9 to 16.9 years had endoscopic features typical of gastric HP. All but one lesion was located in the gastric antrum and most appeared as an umbilicated submucosal nodule measuring 1-2 cm in diameter. Five of 13 children with repaired esophageal atresia (EA) and two of nine children with trisomy 21 had gastric HP. The prevalence of endoscopically visualized gastric HP in children without a history of EA or trisomy 21 was 1.1%.

CONCLUSIONS

Gastric HP is present in about 1% of pediatric upper GI endoscopies. It is significantly more common in patients with EA and may also be associated with trisomy 21. Gastric HP typically appears as a single 1-2 cm antral submucosal nodule, usually with a central pit. Recognition of this lesion is important to avoid misdiagnosis and inappropriate treatment.

LEVEL OF EVIDENCE

Level II (diagnostic).

Primary acquired gastric outlet obstruction in children: A retrospective single center study

BACKGROUND/ PURPOSE

Idiopathic hypertrophic pyloric stenosis is by far the most common cause of gastric outlet obstruction (GOO) in young infants, with more than 90% of cases presenting between 3 and 10 weeks after birth. While cases of late onset pyloric stenosis beyond infancy have been reported, the etiology is poorly understood. We report our experience of 5 cases, describing the similarities and differences in management of our patient population which happens to be the second largest reported in literature.

METHODS

From July 2014 to June 2018 (4 years) a total of five patients of primary acquired GOO were encountered at our center.

RESULTS

The age range was 3 to 6 years and only one of them was a female. All presented with characteristic nonbilious vomiting that was recurrent and episodic. Upper GI (gastrointestinal) contrast study series revealed a dilated stomach and delayed gastric emptying. Upper GI endoscopy also demonstrated a dilated stomach without any intraluminal polyp, ulcer or any other pathology. Intraoperatively the pylorus had no evidence of scarring, inflammation, external compression or any mass in and around the pylorus. A retrocolic gastrojejunostomy was curative in all patients.

CONCLUSION

Though rare, one must maintain a high index of suspicion for primary acquired GOO in the differential diagnosis of older children with nonbilious vomiting and failure to thrive. Following appropriate diagnostic workup, surgical interventions should be performed expeditiously because adequate nutrition is key to proper physical and mental development of the child. Further research will hopefully elucidate the underlying pathophysiology in order to guide clinical options for both prevention and treatment.

TYPE OF STUDY

Retrospective single center study.

LEVEL OF EVIDENCE

Level 4.

Endoscopic submucosal dissection for gastric ectopic pancreas: a single-center experience

BACKGROUND AND OBJECTIVE

Endoscopic submucosal dissection (ESD) is a minimal invasive technology and could allow "en bloc" resection for superficial gastric tumors. The aim of this study is to evaluate the safety and feasibility of ESD for gastric ectopic pancreas (EP).

METHODS

A total of 93 patients diagnosed with ectopic pancreas who underwent ESD between January 2011 and June 2017 were enrolled. The demographic, clinical, and endoscopic data were collected and analyzed.

RESULTS

The average maximal diameter of lesions was 1.01 (range 0.4-3.0) cm with mean age of patients which was 39.75 (range 15-66) years. Overall, all of procedures en bloc was successful. The median operative time was 76.87 (range 30-160) min. A total of 12 patients experienced complications. In seven patients, bleeding occurred during the operation and was treated using hot biopsy forceps or metal clip. Five cases suffered from pneumoperitoneum which was managed well. The mean length of postoperative hospital stay was 5.7 (range 2-17) days. There was no relapse in any cases during the follow-up.

CONCLUSION

ESD appears to be a safe and feasible approach for curative treatment in gastric ectopic pancreas. Larger studies are needed to identify the role and the outcomes of ESD in another center.

Gastric heterotopic pancreas and stromal tumors smaller than 3 cm in diameter: clinical and computed tomography findings

BACKGROUND

Identifying gastric heterotopic pancreas and stromal tumors is difficult. Few studies have reported computed tomography (CT) findings for differentiating lesions less than 3 cm in diameter. In this study, we aimed to identify clinical characteristics and CT findings that can differentiate gastric heterotopic pancreatic lesions from stromal tumors less than 3 cm in diameter.

METHODS

A total of 132 patients with pathologically confirmed gastric heterotopic pancreas (n = 66) and stromal tumors (n = 66) were included. Each group was divided into primary (n = 50) and validation cohort (n = 16). Clinical characteristics and CT findings were retrospectively reviewed. CT findings included location, border, contour, growth pattern, enhancement pattern and grade, the enhancement value of tumor, enhancement ratio of tumor, and enhancement ratio of tumor to pancreas in venous phase. The findings in the two groups were compared using the Pearson χ² test or Student t-test. Receiver operating characteristic curves were used to determine areas under the curve and optimal cut-offs.

RESULTS

Significant differences were observed between heterotopic pancreas and stromal tumors in the distribution of tumor location, border, contour (all P < 0.001), enhancement values (P < 0.001), enhancement ratios of tumors (P < 0.001), and enhancement ratios of tumors to pancreas (P < 0.001). No significant differences existed in growth pattern (P = 0.203). The area under the curve differed significantly between enhancement ratio of tumor to pancreas and enhancement ratio (P = 0.030). There were significant differences in above characteristics between two groups in validation cohort.

CONCLUSIONS

Heterotopic pancreas has characteristic CT features differentiating it from stromal tumors.

Interventional endoscopic ultrasound for a symptomatic pseudocyst secondary to gastric heterotopic pancreas

Heterotopic pancreas (HP) is a relatively uncommon entity that is defined as pancreatic tissue without a true anatomical or vascular connection to the pancreas. HP does not cause symptoms in most cases but can occasionally produce various manifestations, including nausea, vomiting, abdominal pain, and even heterotopic pancreatitis. Here, we report an unusual case in which heterotopic pancreatitis complicated by the formation of a pseudocyst that caused gastric outlet obstruction was diagnosed based on serum hyperamylasemia and findings from endoscopic ultrasonography (EUS)-guided fine needle aspiration (EUS-FNA) cytology. EUS-guided single pigtail stent insertion was successfully performed for recurrent gastric outlet obstruction. The patient has remained healthy and symptom-free during 4 years of surveillance. In the context of the relevant literature, the described case is a rare case of HP complicated by a pseudocyst treated via EUS-FNA and stent insertion.