Changing Pattern of Ectopic Pancreas: 22 Years of Experience in a Medical Center

Gastric and intestinal ectopic pancreas: Two case reports

BACKGROUND

Ectopic pancreas may be unfamiliar to many people because it is rare and difficult to diagnose. However, this disease is highly susceptible to misdiagnosis and missed diagnosis. In this article, we report two cases of pancreatic heterotopia in the gastric sinus and small intestine, respectively, both of which were confirmed by histopathological examination.

CASE SUMMARY

The first patient was a 43-year-old female which reported abdominal distension for 2 mo. The second was a 67-year-old female who experienced intermittent epigastric discomfort for 15 d. In both cases, there was no confirmed preoperative examination, and the postoperative pathology indicated the presence of ectopic pancreas.

CONCLUSION

The diagnosis of ectopic pancreas is difficult, and is often prone to misdiagnosis and the possibility of being overlooked. Various laboratory tests and imaging tests should be carefully evaluated before surgery to achieve early detection, early diagnosis and early treatment.

Metastasis from Renal Cell Carcinoma to Ectopic Pancreas Diagnosed after Resection

We herein report a 68-year-old man who underwent nephrectomy for right renal cell carcinoma 10 years prior. He remained under regular medical observation, and abdominal computed tomography showed tumors in the head and tail of the pancreas. He was diagnosed with pancreatic metastasis from renal cell carcinoma. He underwent surgical excision. The pathologic diagnosis proved that the pancreatic tumors were metastases from renal cell carcinoma and clarified that an ectopic pancreas in the duodenum had metastases as well. To our knowledge, this is the first case of metastasis to an ectopic pancreas.

Pancreatic Heterotopia in the Small Bowel: A Case Report and Literature Review

ABSTRACT

Diagnosing pancreatic heterotopia (PH) is challenging, because it is a rare congenital anomaly. We report the case of a 66-year-old man who presented with ileus and jejunal PH diagnosed using single-balloon enteroscopy. Reviewing 178 cases of small intestinal PH in the literature showed that (1) PH mostly occurred at the duodenum (61.8%), followed by the jejunum (22.5%) and ileum (14.6%); (2) patients with ileal PH were younger (mean, 40.7 vs 54.6 years; P < 0.001), while those with jejunal PH were older (mean, 59.5 vs 51.7 years; P = 0.006); (3) most patients with jejunal PH were females, while those with duodenal or ileal PH were predominantly males (M:F = 0.8:1 vs 2.5:1; P = 0.003); (4) asymptomatic cases were rare (15.2% vs 83.4% in small and nonsmall bowel, respectively); (5) most patients with ileal PH presented with bleeding (61.5%), while the remaining had abdominal pain (42.8%); (6) emergent operation was performed in 11 cases (6.2%), mainly at the jejunum (12.5%) and Meckel's diverticulum (25%); and (7) Heinrich's classification may be inconclusive. Enteroscopy was performed in only 6 cases (3.4%), and earlier diagnosis and further minimally invasive procedures could have been achieved with enteroscopy.

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.

Primary pancreatic cancer of the jejunum: a case report and brief review of literature

The variable clinical presentation of heterotopic pancreatic (HP) tissue and its malignant transformation makes the diagnosis very challenging. These lesions are very rare, usually not suspected upon initial presentation and for the most part, are diagnosed incidentally on review of pathology following surgical resection. In this study, we are reporting an adenocarcinoma arising from jejunal heterotopic pancreatic tissue in a 59-year-old female and a brief review of previously reported cases.

Combination of ectopic pancreas and intestinal malrotation presenting as non-specific right iliac fossa pain in a SARS-CoV-2 positive patient

We describe the case of a 31-year-old man who presented with a 3-day history of right iliac fossa pain with associated nausea and vomiting. He denied any previous incidents of abdominal pain and had no relevant medical history or family history to note. Given the typical history, examination findings of localised peritonism and infection risk, he was taken to theatre for laparoscopic appendicectomy without diagnostic imaging. Intraoperatively, we noted gut malrotation and an inflammatory jejunal mass which was resected after converting to a mini-laparotomy. The inflammatory mass was reported to be an ectopic pancreatic tissue from histology. Given that this patient had tested positive for SARS-CoV-2 on admission, we propose a possible case of SARS-CoV-2 infection triggering inflammation of the ectopic pancreatic tissue.

A rare case of heterotopic pancreatitis and intestinal malrotation in a COVID-19 positive patient. COVID-19, causative or coincidence?

Introduction and importance

Heterotopic pancreas (HP) is defined as the presence of pancreatic tissue without anatomical and vascular continuity with the main body of the pancreas. HP typically remains asymptomatic, however complications such as acute pancreatitis can arise. Gastrointestinal involvement with coronavirus disease 2019 (COVID-19) is not uncommon and there are reported cases of associated pancreatitis.

Case presentation

A 31-year-old male presented to the Emergency department (ED) with a 3-day history of right iliac fossa pain. The patient was found to have COVID-19 and a planned laparoscopic appendectomy was later converted to a midline laparotomy when a mass close to the duodeno-jejunal (DJ) flexure was identified. Following a hand-sewn anastomosis the patient made a good post-operative recovery. Histology illustrated the presence of heterotopic pancreatic tissue within the small bowel with underlying fat necrosis typical of acute pancreatitis. Follow-up radiology supported the intraoperative finding of intestinal malrotation.

Clinical discussion

Rarely the combined presence of intestinal malrotation and HP in patients has been noted. Heterotopic pancreatitis can present in a multitude of ways and it is a difficult diagnosis to make pre-operatively. Emerging literature documents the potential presentation of COVID-19 with acute pancreatitis. The expression of angiotensin-converting enzyme 2 (ACE2) receptors on the pancreas is believed to play a role.

Conclusion

This is the first documented case of heterotopic pancreatitis with intestinal malrotation in a COVID-19 positive patient. We hypothesise that the COVID-19 infection contributed to the heterotopic pancreatitis.

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Heterotopic pancreas can be present in up to 13.7% of patients.

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Heterotopic pancreatitis is a rare complication.

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Pre-operative diagnosis of heterotopic pancreatitis is difficult.

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COVID-19 can induce pancreatic injury and potentially acute pancreatitis.

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COVID-19 may have contributed to the heterotopic pancreatitis in our patient.

Evaluation and management of a pancreatic rest noted during pre-bariatric surgery screening endoscopy

INTRODUCTION

Pancreatic rest (PR) is an ectopic pancreatic lesion that is usually found incidentally on endoscopy or surgery. While most lesions do not have clinical significance, some patients are symptomatic and rarely, PR can predispose to malignancy. With the growing popularity of bariatric surgery, it has been unclear how to manage PR found on screening endoscopies, prior to bariatric surgery. Through review of the current literature, we propose an algorithm for clinicians to evaluate and manage PR found on screening endoscopies prior to bariatric surgery.

METHODS

We performed a literature search in PubMed pertaining to PR, clinical characteristics, risk of malignant transformation, endoscopic characteristics, histological descriptions, and resection techniques. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found 33 published articles from 2001 to 2019, including case reports, case series, retrospective cohorts, and a review paper.

RESULTS

PR is commonly found incidentally in the gastric antrum. Larger lesions have a higher risk of being symptomatic or predisposing to malignant transformation. Endoscopic ultrasound (EUS) can assist in the diagnosis of PR and guide resection technique. Certain histological characteristics, such as Heinrich class, grading of neoplasia, and genetic alterations, can determine malignancy risk of PR. Resection technique, either endoscopically or surgically, should be based on lesion size, depth of wall invasion, and the endoscopists' level of skill in endoscopic resection.

CONCLUSIONS

Proper evaluation and treatment of PR should be considered because of the risk for symptoms and malignant transformation. Symptomatic lesions and those at risk for malignant transformation should be considered for resection. EUS can guide the diagnosis and type of resection, either endoscopically through EMR or ESD or surgically through sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB).

The role of autofluorescence, photodynamic diagnosis and Photodynamic therapy in malignant tumors of the duodenum

This article presents the current state of knowledge and a review of the literature in terms of the prevalence, etiopathogenesis, differential diagnosis, management, prognosis, and treatment of malignant tumors of the duodenum. The role of autofluorescence and photodynamic diagnosis as an emerging treatment method for rarely o ccurring duodenal malignant neoplasms .. We selected publications which can be found in databases such as The National Center for Biotechnology Information, U.S. National Library of Medicine (PubMed), The American Chemical Society, The American Association of Pharmaceutical Sciences and The American Society for Photobiology and The Canada Institute for Scientific and Technical Information.

Intramural ectopic pancreatic tissue of the stomach: A case report of an uncommon origin of a non-cancerous gastric tumour

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Ectopic pancreatic tissue is a rare incidental finding during abdominal surgery.

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80% of the lesions are unifocal and less than 3 cm in size.

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The most frequent site is the stomach, followed by duodenum and proximal jejunum.

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The imaging modalities and endoscopic biopsy often remain inconclusive.

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Only resection and and histopathologic examination provide the definitve diagnosis.

Introduction

Ectopic pancreatic tissue is often incidentally encountered during abdominal surgery. We report a case of an incidental finding during a laparoscopic appendectomy, the approach to diagnosis and management of this.

The work has been reported in line with the SCARE criteria.

Presentation of case

A 32 year-old woman was diagnosed with an intramural pre-pyloric mass during a laparoscopic appendectomy. The lesion was identified on a subsequent computed tomography as a homogenous mass on the greater curvature. Upper esophagho-gastro-duodenoscopy was normal. The intramural mass was confirmed by an endoscopic sonography and the fine needle biopsy showed aspecific inflammatory cells. A laparoscopic wedge resection was realized. Histopathologic examination confirmed the diagnosis of an ectopic pancreatic tissue.

Discussion

The management of ectopic pancreas poses a medical challenge. The diagnostic quiver consists of radiologic exams and endoscopy, in combination with a direct biopsy of the lesion.

Conclusion

Despite the plethora of diagnostic modalities available, a definitive diagnosis for heterotopic pancreas often remains elusive, requiring more invasive diagnostic means. Although ample information is available in literature, there are currently no evidence-based guidelines regarding diagnosis and management of heterotopic pancreas.

Benign and non-neoplastic tumours of the duodenum

This review study describes the problem of duodenal tumours, which are rare but important in gastrological practice. The most common location of small intestinal tumours is the duodenum, and this observation is probably partly due to the greater diagnostic availability for most proximal segments of the small intestine. Among tumours the following should be mentioned – benign: adenomas, lipomas, haemangiomas, and leiomyomas; and malignant: malignant tumours of epithelial origin, primary gastrointestinal stromal tumours, neuroendocrine tumours and carcinoids, lymphomas, sarcomas, teratomas, and secondary metastases. Early duodenal tumour recognition, especially with histological assessment, plays a crucial diagnostic role with future therapeutic implications. In recent years the prevalence of benign duodenal tumours has been rising due to a higher level of clinicians’ doubts and the convenience of gastrointestinal endoscopy; hence, knowledge of this problem is important in routine clinical practice. The method of duodenal tumour treatment should be selected on an individual basis.

Heterotopic pancreas in the gastrointestinal tract in children: a single-center experience and a review of the literature

Background

Heterotopic pancreas, that is the abnormal localization of a well-differentiated pancreatic tissue, is a rare occurrence in pediatric patients. Most lesions are found incidentally; in some circumstances, the presence of heterotopic pancreas may cause gastrointestinal symptoms, such as obstructive symptoms or bleeding.

Patients and methods

The clinical notes of patients with histological diagnosis of heterotopic pancreas treated at Meyer Children’s Hospital between 2009 and 2017 have been retrospectively examined.

Four variables have been examined: clinical presentation, age at diagnosis, timing of surgery and localization of the heterotopic pancreas. Patients have been classified accordingly.

Results

Fourteen patients were diagnosed with heterotopic pancreas at a single institution. In half cases, heterotopic pancreas caused symptoms that warranted surgical exploration. Symptomatic patients were significantly older than patients in whom heterotopic pancreas was an incidental finding (mean age 9 years and 5 months vs 2 years and 9 months; p = 0.02). Heterotopic pancreas was more frequently found in patients who underwent urgent surgical procedure than in patients who underwent elective surgery (2.61% vs 0.22%; p < 0.0001). In all cases, foci of heterotopic pancreas were resected.

Conclusion

Heterotopic pancreas is usually discovered in the submucosa of the stomach, duodenum and small bowel. Heterotopic tissue may cause symptoms related to mechanical complications, bleeding from the surrounding intestinal mucosa or, occasionally, to the development of malignancy.

Heterotopic tissue is a rare but clinically relevant cause of gastrointestinal symptoms. The presence of heterotopic tissue should be considered in children with gastrointestinal symptoms of unclear origin and surgical resection is advisable.

Ectopic pancreas in the ileum: An unusual condition and our experience

BACKGROUND

Ectopic pancreas in the ileum, including lesions within Meckel diverticulum, can cause severe manifestations and complications; yet, it was seldom reported in English literature.

AIM

This study aimed to raise awareness and provide information for better clinical management of this rare yet serious condition.

METHODS

A total of 1713 cases of small bowel resection were performed in our hospital between 2009 and 2018, among which 10 cases of ileac ectopic pancreas were identified. A comprehensive retrospective review of the 10 cases was taken.

RESULTS

Five lesions were located in the ileum wall and 5 were within Meckel diverticulum. Two lesions within Meckel diverticulum were incidental; the remaining 8 lesions were all associated with abdominal pain, gastrointestinal bleeding, and anemia. Of the 5 patients with lesions in the ileum wall, computed tomography uniformly revealed ileoileal intussusceptions with masses as lead points. Capsule endoscopies were performed in 6 cases, of which 3 showed positive findings. Double-balloon enteroscopy was conducted in one case and revealed an ileal diverticulum. Therapeutically, the offending bowel segments were removed, and intussusceptions were restored except for one case in which diverticulectomy was applied. No relapse or sequela was observed in the follow-up.

CONCLUSIONS

Ileac ectopic pancreas can be seen in the ileum wall or Meckel diverticulum. The majority of the lesions found in clinical practice present with abdominal pain, gastrointestinal bleeding, and anemia. Lesions in the ileum wall often cause ileoileal intussusception. Computed tomography, capsule endoscopy, and double-balloon enteroscopy are helpful preoperative examinations. Segmental small bowel resection is the treatment of choice.

A case of ectopic pancreas in the ileum presenting as obscure gastrointestinal bleeding and abdominal pain

Background

Ectopic pancreas is an infrequent submucosal tumor in the gastrointestinal tract defined as a pancreatic tissue lacking vascular or anatomic continuity with the main body of the pancreas. Ectopic pancreas in the ileum is a rare and often an incidental finding. We report a case of ectopic pancreas in the ileum causing obscure gastrointestinal bleeding and episodes of abdominal pain.

Case presentation

59-year-old man with 3 months history of intermittent melena, accompanied by the episodes of abdominal pain in the left upper quadrant and generalized fatigue was admitted to our department. The investigations showed that the patient had a low hemoglobin level, i.e. 10.9 g/dL with hypochromic microcytic anemia pattern seen in complete blood count (MCV 70.2 fl, MCH 21.4 pg). Esophagogastroduodenoscopy and colonoscopy did not reveal any abnormalities. Magnetic resonance enterography revealed a large (2.5 × 2.3 cm) pedunculated polyp in the ileum. Examination by single-balloon enteroscopy revealed a polyp with long pedicle located approximately 1.5 m distal to terminal ileum. Polypectomy was performed. Histopathologic examination stated, that the specimen contained ectopic pancreatic tissue which was involving muscular layer of the ileum. Ectopic pancreatic tissue included acinar cells and cystically dilated secretory ducts without islets of Langerhans.

Conclusion

Our case report reveals a very rare cause of obscure gastrointestinal bleeding accompanied by the episodes of abdominal pain – an ectopic pancreas located in the ileum.

Ectopic pancreas in the upper gastrointestinal tract: Is endosonographic diagnosis reliable? Data from the German Endoscopic Ultrasound Registry and review of the literature

Background:

Ectopic pancreas (EP) belongs to the most frequent subepithelial lesions (SELs) of the upper gastrointestinal (GI) tract. In the majority of cases, it is detected incidentally. Differential diagnosis from mesenchymal subepithelial tumors may be difficult.

Methods:

Among 24,308 endosonographic examinations and interventions, which were prospectively enrolled in the database of the German Endoscopic Ultrasound (EUS) Registry from January 2009 to August 2013, 575 were performed for suspected SELs of the upper GI tract. Sixty three cases of EP of the upper GI tract (stomach, n = 53; duodenum, n = 10; esophagus, n = 0) were extracted and retrospectively reviewed.

Results:

In 65.1% of cases, radial echoendoscopes or radial miniprobes were used for examination. Nearly 84% of EP was found in the stomach, 16% in the duodenum, none in the esophagus. In 88.9% of cases, the EUS examination discerned the layer of origin. In 59% of cases EP was described as a heterogeneous, in 28.6% as a homogeneous-hypoechoic and in 7.9% as a homogeneous-echogenic subepithelial mass lesion. Mean diameter was 13.0 mm × 8.1 mm, the mean ratio between long and short axis diameter was 1.75. EUS-guided fine needle aspiration (EUS-FNA) was used to accomplish cytological or histological diagnosis in only 6.3% of cases.

Conclusions:

EP accounts for 11% of all EUS examinations performed for subepithelial lesions of the upper GI tract and prospectively enrolled in the German EUS registry. Rather than being an eyecatcher, EP is a chameleon with numerous differential diagnoses. In selected cases, EUS-FNA may help clarifying the diagnosis.

Heterotopic Pancreas of the Gastrointestinal Tract and Associated Precursor and Cancerous Lesions: Systematic Pathologic Studies of 165 Cases

Heterotopic pancreas (HP) can be detected by accompanying symptoms or incidentally during gastrointestinal (GI) tract tumor resection. We compared clinicopathologic features among 165 resected HPs (57 gastric [35%], 56 duodenal [34%], 30 omental [18%], and 22 jejunal [13%]). Symptomatic HPs (79/135 GI tract wall HPs, 59%) were larger (P=0.05), more common in younger patients and in a gastric location (both P<0.001), and more frequently associated with lymphoid cuffs (P=0.03) than incidentally found HPs. Gastric/jejunal HPs were more frequently symptomatic (P<0.001), deeply located (P=0.03), and associated with lymphoid cuffs (P=0.008) and pancreatic intraepithelial neoplasia/intraductal papillary mucinous neoplasms (PanIN/IPMN; P=0.001) than duodenal HPs. HP was frequently associated with acinar-ductal metaplasias (117/135 GI tract wall HPs, 87%) and PanINs/IPMNs (68/135, 50%); those with PanINs/IPMNs were larger (P<0.001), more frequently located in stomach (P=0.001), had deeper wall involvement (P=0.03), and more often showed infiltrative growth (P<0.001) and lymphoid cuffs (P=0.02). Four HPs containing PanINs abutted adenocarcinomas, all expressing wild-type KRAS and intact SMAD4/DPC4 expression. Thus, symptomatic HP is associated with younger age, larger size, gastric location, and lymphoid cuffs. HPs containing PanINs/IPMNs (usually low grade) are larger and more common in stomach, have deeper wall location, and show infiltrative growth and lymphoid cuffs. Adenocarcinomas are rarely observed adjacent to HPs with PanINs/IPMNs. KRAS mutational and SMAD4/DPC4 immunohistochemical studies can discriminate between adenocarcinoma derived from HP and concurrent adenocarcinoma with HP.

Heterotopic pancreas: a clinicopathological study of 184 cases from a single high-volume medical center in China

Heterotopic pancreas (HP) is often an incidental finding during operative or endoscopic procedures and described in case reports and small series in the literature. Large clinicopathological studies with a systematic analysis remain lacking. Herein, we identified 184 (0.18%; 184/99 544) consecutive histology-proven HP cases of 89 770 surgical resections and 9774 upper endoscopic biopsies carried out at a single medical center in China. Each case was diagnosed by unequivocal identification of pancreatic acini at a location outside the pancreas. The patients' median age was 49 years (range, 14-82) with a slight female predominance (male/female ratio, 0.94). Clinical presentation at diagnosis was nonspecific. Preoperatively, most (54.9%; 101/184) HP lesions were misdiagnosed. Only 26 HP lesions (14.1%) were correctly diagnosed, all in the stomach except for 1 in the duodenum; 57 (31%) were detected during operative procedures for other conditions. The most frequent location of HP was, in descending order, the stomach (97; 52.7%), small intestine (48; 26%), lesser and greater curvature omentum (18; 10%), spleen and hilar region (5; 2.7%), porta hepatis (2; 1%), gallbladder (1; 0.5%), peridistal esophageal tissue (4; 2.2%), and mesentery (7; 3.8%). The size of HP varied from smaller than 0.5 cm (35.3%), 0.6 to 1 cm (34.8%), to larger than 1.1 cm (29.9%). Because of difficulty in preoperative diagnosis, careful workup for upper gastrointestinal diseases with HP as a differential diagnosis may increase the chance of accurate diagnosis and appropriate patient management.

Cytology findings in pancreatic heterotopia, a potential pitfall for malignancy: a case report and literature review

Pancreatic heterotopia is a rare congenital disorder occurring at a variety of sites in the gastrointestinal tract. It is rarely symptomatic. Despite advances in diagnostic techniques, it still remains a challenge to the clinician to differentiate it from a neoplasm. Cytologic characteristics of pancreatic heterotopia in general are rarely described in the literature. We report the cytologic characteristics of heterotopic pancreatic tissue at the gastric outlet in a 48-year-old female. The patient underwent surgical excision due to symptoms related to the lesion. Endoscopic ultrasound fine-needle aspiration is increasingly used for the diagnosis of gastrointestinal tumors, which makes the recognition of certain endoscopically unreachable lesions an important step in optimal patient management.

Ectopic pancreas bleeding in the jejunum revealed by capsule endoscopy

Ectopic pancreas is defined as pancreatic tissue found outside the usual anatomic location. It is often found incidentally at different sites in the gastrointestinal (GI) tract. The incidence of ectopic pancreatic tissue in autopsy series is 1% to 2%, with 70% of the ectopic lesions found in the stomach, duodenum and jejunum. Although it is usually a silent anomaly, an ectopic pancreas may become clinically evident when complicated by inflammation, bleeding, obstruction or malignant transformation. We report a case of ectopic pancreas located in the jejunum and presenting as an obscure GI bleeding, which was diagnosed by capsule endoscopy.

Adenocarcinoma with intraductal papillary mucinous neoplasm arising in jejunal heterotopic pancreas

A 74-year-old man suffered from jejunal perforation and adhesion to sigmoid colon due to adenocarcinoma associated with intraductal papillary mucinous neoplasm (IPMN) arising in a jejunal heterotopic pancreas. The jejunal lesion showed direct extension to the sigmoid colon, which was mistaken as sigmoid colon cancer by surgeons. Malignant transformation is a rare complication of a heterotopic pancreas. About half of malignancies in reported cases were ductal adenocarcinoma arising in the stomach, and the jejunal location is extremely rare. Furthermore, IPMN is also uncommon finding in a heterotopic pancreas.