Gastric obstruction due to intramural pseudocyst associated with heterotopic pancreas

Gastric ectopic pancreas with a pseudocyst

Ectopic pancreas (EP) is defined as pancreatic tissue that lacks anatomical or vascular connections to the normal pancreas. EP is generally asymptomatic and is detected incidentally during endoscopy. However, due to pseudocyst formation, inflammation, or malignant transformation, it may cause non-specific gastrointestinal symptoms, such as abdominal pain, abdominal discomfort, nausea, vomiting, and bleeding. Pseudocyst formation in EP may result from the retention of exocrine secretions in the absence of connections between the glandular epithelium and gastric lumen. We herein report a case of EP with a pseudocyst associated with epigastric pain. EP with a pseudocyst, although rare, needs to be considered in a differential diagnosis of cystic lesions of the stomach.

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.

Duodenal Heterotopic Pancreas with a Large Retention Cyst: A Case Report and Literature Review

A 75-year-old man was referred to our hospital with a suspected pancreatic cyst. Imaging tests revealed a 3-cm cystic lesion located ventrally in the duodenal bulbus, which was suspected to be a duplication cyst with its muscularis propria contiguous to that of the duodenum. One year later, the cyst grew to 6 cm due to intracystic hemorrhaging; therefore, surgery was performed. Histopathology revealed a heterotopic pancreas (HP) in the duodenal wall. The diagnosis was a large, non-malignant retention cyst. Inflammation due to impaired outflow of pancreatic juice from the HP was identified as the cause of cyst enlargement.

Gastric Ectopic Pancreas With Pseudocyst Formation Causing Gastric Outlet Obstruction

Ectopic pancreas is a rare entity referring to the presence of pancreatic tissue at an anatomic location distinct from the pancreas. Ectopic pancreatic lesions in the stomach present a diagnostic challenge because the lack of distinguishing imaging and endoscopic features make them difficult to differentiate from other types of submucosal lesions. We report a case of ectopic pancreas presenting as a gastric antral mass with a unique combination of rare complications: chronic pancreatitis and pseudocyst formation causing gastric outlet obstruction. This case highlights complications that can occur from ectopic pancreatic lesions and the challenges of diagnosing ectopic pancreas.

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.

Insight into gastrointestinal heterotopic pancreas: imaging evaluation and differential diagnosis

Heterotopic pancreas (HP) is an uncommon congenital abnormality in the developmental process of the pancreas, with gastrointestinal heterotopic pancreas (GHP) being the most common HP. The clinical manifestations of GHP may have variable patterns of presentation, dictated by both the anatomic location and the functional ability of the lesion. The most common imaging modality in detecting GHP is computed tomography (CT), while gastrointestinal barium fluoroscopy, endoscopic ultrasonography, and magnetic resonance imaging (MRI) are also applied. The density and enhancement patterns of GHP are consistent with histological classifications. GHP with a predominantly acinar tissue component manifests homogeneous and marked enhancement on CT images, whereas a predominantly ductal GHP presents heterogeneous and mild enhancement. On MRI, the appearance and signal intensity of GHP were paralleled to the normal pancreas on all sequences and were characterized by T1-weighted high signal and early marked enhancement. This article provides a comprehensive review of the histopathology, clinical manifestations, imaging features of various modalities, and differential diagnosis of GHP. It is hoped that this review will improve clinicians' knowledge of GHP and aid in accurate preoperative diagnosis, thereby reducing the misdiagnosis rate.

Intramural gastric pseudocyst: A case report and a comprehensive literature review

RATIONALE

Intramural pseudocyst, although first reported several decades ago, is a rare entity. Scientific knowledge regarding its clinical management is sparse.

PATIENT CONCERNS

We present three cases to show the diverse clinical patterns of patients diagnosed with an intramural gastric pseudocyst.

DIAGNOSIS

A final diagnosis should rest on proper evaluation by cross sectional imaging, including computer tomography and magnetic resonance imaging. Endoscopic ultrasound adds to the work-up.

INTERVENTIONS

Previously, identified "lesions of the gastric wall" were not well recognized as an intramural pseudocyst, and treatments including resectional surgery were employed. Contemporary proper diagnostics should provide support to a less aggressive treatment approach.

OUTCOMES

While an indolent natural history without any clinical symptoms or discomfort could be expected in most cases, individual clinical evaluation should be applied.

LESSONS

A heterogeneous information pattern from the limited number of cases in the literature makes it difficult to draw any firm conclusions. Attention to this rare condition should be increased to help clinicians arrive at a correct diagnosis and possibly prevent some patients from being over treated or from the use of unnecessary surgery.

Endoscopic color doppler ultrasonography in predicting the safety of endoscopic submucosal dissection for antral heterotopic pancreas

BACKGROUND/AIMS

Complications are important determining factors for safety of endoscopic submucosal dissection (ESD) for gastric heterotopic pancreas (HP). This study investigated whether endoscopic color Doppler ultrasonography (ECDUS) could be used to predict the feasibility, efficacy, and safety of ESD.

PATIENTS AND METHODS

The study included 52 patients with heterotopic pancreas of the gastric antrum who underwent ECDUS before ESD. ECDUS was used to evaluate the submucosal vascular structure and the location of HP in gastric wall. The patients who had a vessel at least 500 μm in diameter or at least 10 vascular structures per field of view were classified into the rich group (Group R), and others were classified into the non-rich group (Group N). Procedure time, decrease in hemoglobin, frequency of clip use, complications, recurrence rate, and others were retrospectively evaluated.

RESULTS

There were 18 patients in Group R and 34 patients in Group N. Mean procedure time was significantly longer in group R (55.4 min) than in group N (35.5 min) (P = 0.014). The incidence of muscle injury and clip use were significantly higher in group R (77.8/83.3%) than in group N (20.6/23.5%) (P < 0.05). Mean decrease in hemoglobin was 2.5 g/dL in group R and 2.4 g/dL in group N, with no significant difference. There were no recurrences in any cases during the follow-up period.

CONCLUSION

Preoperative identification of submucosal vascular structure by ECDUS can predict procedure time and the incidence of muscle injury and clip use, which is particularly suitable for predicting ESD safety in heterotopic pancreas of stomach.