Heterotopic pancreas: a difficult diagnosis

Acute peritonitis caused by the acute pancreatitis of an ectopic pancreas in a jejunal duplication, in an adult with intestinal malrotation: a case report

BACKGROUND

Intestinal duplication and ectopic pancreas are two rare independent congenital anomalies. Few reports describe cases of patients with ectopic pancreas in an intestinal duplication causing acute peritonitis.

CASE PRESENTATION

A 31-year-old man was admitted to the hospital for epigastric pain. The patient was diagnosed with acute peritonitis caused by the acute pancreatitis of an ectopic pancreas in a jejunal duplication, with intestinal malrotation. The patient underwent the partial resection of the jejunum and Ladd's procedure. The histopathological findings indicated ectopic pancreatitis in the jejunal duplication.

CONCLUSIONS

We presented the case of acute peritonitis caused by the acute pancreatitis of an ectopic pancreas in a jejunal duplication in an adult with intestinal malrotation. Surgery is the primary treatment and is necessary for a definitive diagnosis.

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.

Use of computed tomography for distinguishing heterotopic pancreas from gastrointestinal stromal tumor and leiomyoma

PURPOSE

To determine whether morphologic features and semiquantitative parameters of computed tomography (CT) could be used to distinguish heterotopic pancreas from gastrointestinal stromal tumor (GIST) and leiomyoma.

METHODS

This retrospective study evaluated CT images of heterotopic pancreases (n = 28), GISTs (n = 57), and leiomyomas (n = 26) located in the upper gastrointestinal tract. Morphologic imaging features of lesions were analyzed, including location, contour, margin, attenuation, growth pattern, enhancement type, enhancement degree, enlarged vessels feeding or draining the mass, hyperenhancement of the overlying mucosa, low intralesional attenuation, calcification, and a duct-like structure. Semiquantitative parameters included long diameter (LD), short diameter (SD), LD/SD ratio, and lesion and aorta CT values during plain CT (Lp and Ap), arterial phase (La and Aa), and venous phase (Lv and Av). Diagnostic performance of these findings and parameters were evaluated by receiver operating characteristic (ROC) analysis.

RESULTS

Morphologic CT findings (including lesion contour, margin, attenuation, growth pattern, enhancement type, and enhancement degree) and semiquantitative parameters except for LD/SD were demonstrated to be significant for differentiating heterotopic pancreas from GIST and leiomyoma (all P < 0.01). Of these, location, low intralesional attenuation, duct-like structure and LD, SD, Lv, and Sv values showed good diagnostic performance with the areas under curve (AUC) higher than 0.70. The presence of a duct-like structure demonstrated the best diagnostic ability with AUC of 0.929 [95% confidence interval (CI) 0.864-0.969], sensitivity of 5.7% (95% CI 67.3-96.0), and specificity of 100% (95% CI 95.7-100), respectively. When the three morphologic features (location, low intralesional attenuation, duct-like structure) were used in combination, the AUC was improved to 0.980 (95% CI 0.952-1).

CONCLUSION

CT features, especially the morphologic features, could be used to differentiate heterotopic pancreas from GIST and leiomyoma in the upper gastrointestinal tract and, thus, provide a more accurate method for non-invasive preoperative diagnosis. Additionally, the presence of a duct-like structure demonstrated to be a reliable indicator for heterotopic pancreas among the morphologic and semiquantitative CT features.

Concomitant Heterotopic Pancreas and Endometriosis as a Rare Cause of Ileo-Ileal Intussusception in a Young Woman with Spina Bifida: Case Report and Literature Review

INTRODUCTION

Isolated heterotopic pancreas (HP) as the primary cause of bowel intussusception is extremely rare. We report a case of a 33-year-old female patient with spina bifida admitted to the Emergency Surgical Department for ileal intussusception due to the presence of heterotopic pancreas associated with endometriosis.

AREAS COVERED

Symptomatic ileal intussusception for ectopic pancreas is usually associated with overt gastrointestinal blood loss (predominantly melena), abdominal pain, vomiting, and weight loss. Treatment is universally surgical.

EXPERT COMMENTARY

Isolated heterotopic pancreas is a rare condition; it should be considered in the differential diagnosis of bowel intussusception.

Incidental Duodenal Pancreatic Heterotopia During Laparoscopic Sleeve Gastrectomy: A Case Report and Literature Review

Patient: Male, 15

Final Diagnosis: Duodenal pancreatic heterotopia

Symptoms: None

Medication: —

Clinical Procedure: Wedge resection and primary repair

Specialty: Surgery

Invasive ductal adenocarcinoma arising from heterotopic pancreas in the jejunum: Case report and literature review

Although the presence of pancreatic tissue outside of the usual anatomical location of the pancreas is not an uncommon incidental finding, the risk of malignancy is extremely low. We report a case of ductal adenocarcinoma arising within a focus of heterotopic pancreas, occurring in the jejunum of an 81 year old woman. The patient presented with a history of progressive gastrointestinal occlusive symptoms. Computerized tomography showed a mass in the jejunum, which was surgically removed. Histopathology revealed an invasive pancreatic ductal adenocarcinoma from pancreatic tissue with no connection with the original gland (Heinrich type II). At the 12-month follow-up, there were no signs of recurrence. Despite the low risk of malignancy in heterotopic pancreas, adenocarcinoma is the most frequent histological type, and the prognosis is still not clear. Lesions incidentally detected during surgery and in symptomatic patients need to be removed by conservative procedures in order to exclude malignant disease.

From Rare to Neglected Diseases: A Sustainable and Inclusive Healthcare Perspective for Reframing the Orphan Drugs Issue

This work is about how healthcare issues can be reframed from a sustainable and inclusive development perspective. Focusing on the case of orphan drugs and rare diseases, first, a country-based review of the main regulatory approaches to orphan drugs is conducted; then, the main contributions of the literature are reviewed to identify dominant views and the way the problem is more commonly framed. The main findings reveal that the dominant regulatory approaches and theoretical interpretations of the problem are mainly based on economic considerations. However, this does not seem to have led to very satisfactory results. Reflecting upon what the sustainability perspective can highlight with reference to healthcare, substantial connections between the orphan drugs issue and that of neglected diseases are highlighted. These connections suggest reframing the orphan drugs issue as a social equality and inclusiveness problem, hence the need to adopt a sustainable and inclusive development perspective. As a key sustainable development goal (SGD) to be shared by all nations, healthcare should always be approached by putting the principles of sustainable and inclusive development at the core of policy makers’ regulatory choices. Accordingly, we think that the orphan drugs issue, like that of neglected diseases, could be better faced by adopting a social equality and inclusiveness perspective.

Mesenteric heterotopic pancreas in a pediatric patient: A case report and review of literature

Heterotopic pancreas (HP) is a congenital anomaly defined as pancreatic tissue that has no contact with the orthotopic pancreas and its own duct system and vascular supply. The most common locations of HP are the upper gastrointestinal tract, specifically, the stomach, duodenum, and proximal jejunum. Involvement of the mesentery is rare. Here, we describe a rare case of mesenteric heterotopic pancreas (MHP) in a 12-year-old girl who presented with acute abdomen. The patient underwent emergency laparotomy, and the mass and adjacent small bowel were resected. Results of the postoperative histopathologic examination confirmed the diagnosis of MHP. Observation of the patient for 12 mo postoperatively showed no evidence of recurrence. Preoperative diagnosis of HP is difficult, even in a symptomatic patient. Increased awareness and understanding of the image characteristics of MHP will aid in correct preoperative diagnosis and appropriate patient management.

Pancreatic and gastric heterotopic tissue presenting as a symptomatic gallbladder mass: A case report and literature review

Pancreatic and gastric heterotopia is an uncommon congenital anomaly in which gastric and/or pancreatic tissue is found outside of its anatomic location. In the majority of patients, lesions are found incidentally because they tend to be asymptomatic. However, lesions may become symptomatic when inflammation, obstruction, and bleeding occurs. Depending on tissue size and location they can harvest a landscape of nonspecific symptoms, causing a delay in diagnosis. Heterotopic tissue of either gastric or pancreatic origin have been reported in literature, however the presence of combined gastric and pancreatic heterotopic tissue is exceedingly rare. We report a case of an 18-year-old female with polypoid gastric and pancreatic heterotopia and focal intestinal metaplasia of the gallbladder with clinical findings of acute cholecystitis. In this literature review, we synthesize the clinical significance, histopathological features, diagnosis and management of pancreatic and gastric heterotopic tissue.

Ectopic Pancreatic Tissue Adherent to the External Gallbladder Wall

Heterotopic pancreatic tissue can be found in the gastrointestinal tract, with the stomach and small bowel being the most common sites of localization. The gallbladder is seldom affected. Here, we report 2 cases of ectopic pancreas within the fatty tissue adherent to the organ wall. Both cases concerned young women (31 and 36 years old) who were treated with a laparoscopic cholecystectomy due to persistent abdominal symptoms thought to be related to chronic cholecystitis. Pathological examination revealed the presence of ectopic pancreatic tissue type 1.

Ectopic Pancreas Causing Partial Gastric Outlet Obstruction: A Case Report and Review of Literature

Ectopic pancreas is a rare cause of gastric outlet obstruction, perhaps rarer still among Africans. Although the entity is known, the diagnostic challenges are enormous, especially in the poor-resource environment. Gastric outlet obstruction resulting from ectopic pancreas in an adult is the first of its kind in our center; we, therefore, present this case to describe the challenges faced with diagnosis, treatment, and the lesson learned. Ectopic pancreas should be considered in the differential diagnosis of gastric outlet obstruction.

Magnifying endoscopy with narrow-band imaging for gastric heterotopic pancreas

BACKGROUND AND STUDY AIMS

 Heterotopic pancreas is a common subepithelial lesion in the stomach. However, its histological diagnosis is difficult when tissue samples are obtained with a conventional biopsy forceps. This study aimed to describe the magnifying endoscopy with narrow-band imaging (ME-NBI) features of gastric heterotopic pancreas.

PATIENTS AND METHODS

 We retrospectively analyzed a database of all patients who underwent endoscopic ultrasonography (EUS) at Pusan National University Hospital from January 2010 to December 2010. Thirty-six patients with endosonographically diagnosed heterotopic pancreas who underwent ME-NBI and endoscopic ultrasonography (EUS) simultaneously were studied. The ME-NBI features of their lesions were analyzed.

RESULTS

 Thirty lesions were located in the antrum and six in the body. Six lesions (17 %) showed umbilication or central dimpling on the surface, and nine (25 %) had a macroscopic opening on the surface. On ME-NBI, a microscopic opening was identified in 22 (81 %) of 27 lesions wherein a macroscopic opening was not observed during conventional endoscopy. Macroscopic or microscopic opening was observed in 31 lesions (86 %). The frequency of macroscopic or microscopic opening was higher in lesions with anechoic duct-like structures than in lesions without such structures on EUS (91 % [29/32] vs 50 % [2/4], P  = 0.027). Focal loss of microsurface structure and presence of a thickened submucosal vessel were observed in 6 (17 %) and 5 lesions (14 %), respectively.

CONCLUSIONS

The characteristic ME-NBI feature of heterotopic pancreas is presence of a microscopic opening on its surface. This ME-NBI feature is potentially useful for differentiating heterotopic pancreas from other gastric subepithelial tumors.

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.

Clinical impact of duodenal pancreatic heterotopia - Is there a need for surgical treatment?

BACKGROUND

Pancreatic heterotopia (PH) is defined as ectopic pancreatic tissue outside the normal pancreas and its vasculature and duct system. Most frequently, PH is detected incidentally by histopathological examination. The aim of the present study was to analyze a large single-center series of duodenal PH with respect to the clinical presentation.

METHODS

A prospective pancreatic database was retrospectively analyzed for cases of PH of the duodenum. All pancreatic and duodenal resections performed between January 2000 and October 2015 were included and screened for histopathologically proven duodenal PH. PH was classified according to Heinrich's classification (Type I acini, ducts, and islet cells; Type II acini and ducts; Type III only ducts).

RESULTS

A total of 1274 pancreatic and duodenal resections were performed within the study period, and 67 cases of PH (5.3%) were identified. The respective patients were predominantly male (72%) and either underwent pancreatoduodenectomy (n = 60); a limited pancreas resection with partial duodenal resection (n = 4); distal pancreatectomy with partial duodenal resection (n = 1); total pancreatectomy (n = 1); or enucleation (n = 1). Whereas 65 patients (83.5%) were asymptomatic, 11 patients (18.4%) presented with symptoms related to PH (most frequently with abdominal pain [72%] and duodenal obstruction [55%]). Of those, seven patients (63.6%) had chronic pancreatitis in the heterotopic pancreas. The risk of malignant transformation into adenocarcinoma was 2.9%.

CONCLUSIONS

PH is found in approximately 5% of pancreatic or duodenal resections and is generally asymptomatic. Chronic pancreatitis is not uncommon in heterotopic pancreatic tissue, and even there is a risk of malignant transformation. PH should be considered for the differential diagnosis of duodenal lesions and surgery should be considered, especially in symptomatic cases.

Endosonogragphic features of lesions suggesting gastricectopic pancreas: experience of a single tertiary center

BACKGROUND/AIM

We aimed to present the endoscopic ultrasound (EUS) features of gastric lesions suggesting gastric ectopic pancreas during upper gastrointestinal endoscopy that were diagnosed in our gastroenterology unit, which is a tertiary center for endoscopic procedures in Turkey.

MATERIALS AND METHODS

The data of patients who underwent upper gastrointestinal EUS in our center between April 2012 and July 2014 were retrospectively analyzed.

RESULTS

All of the lesions suggesting gastric ectopic pancreas were localized in the gastric antrum. Thirty-six of 44 lesions (81.1%) showed central dimpling. Lesion borders were shown to be definite in 10 (22.7%) lesions, whereas the borders of 34 lesions (77.3%) were indefinite. Thirty-nine lesions (88.6%) had heterogeneous and 5 lesions (11.4%) had homogeneous echo patterns; whereas 29 lesions (65.9%) were hypoechoic, 9 lesions (20.5%) were hyperechoic and 6 lesions (13.6%) had mixed echogenicity. Forty-two lesions (95.5%) were shown to affect only a single sonographic layer of the gastric wall.

CONCLUSION

EUS features of lesions that strongly suggest gastric ectopic pancreas endoscopically, without any histopathological evidence and without either endoscopic or surgical resection, are as follows: indefinite border appearance, minimal heterogeneous hypoisoechoic echo pattern, existence of anechoic duct-like structures inside the lesion, common localization in the submucosal layer, and existence of umbilication.

Ectopic pancreatic tissue in the stomach: Case report

Introduction: Ectopic pancreas is a rare developmental anomaly. It is a presence of pancreatic tissue without anatomic or vascular continuity with the normally developed pancreas. The most common heterotopic site is the stomach commonly involving antrum and prepyloric region on the greater curvature or posterior wall. Ectopic pancreas is diagnosed by endoscopic ultrasound, gastroscopy and biopsy, CT scan and MRI of the abdomen, a definitive diagnosis is verified by histopathological examination. Treatment is surgical. Case report: A 56-year-old woman presented with epigastric pain, nausea and fatigue. Esophagogastroduodenoscopy showed submucosal mass in the prepyloric region, biopsy was performed. Histopathological findings described normal gastric mucosa. Endoscopic ultrasonography and CT of the abdomen showed submucosal tumor, 18 mm in diameter, located in the prepyloric region. Surgical treatment was indicated. Gastrotomy with total extraction of tumor was performed. Histopathology findings showed ectopic pancreatic tissue in the submucosal and muscular layer of the stomach. Postoperatively patient fully recovered, and in the 2 year follow-up did not develop any symptoms related to gastrointestinal tract. Conclusion: Although presentation of ectopic pancreatic tissue in stomach is a very rare condition, it should be considered during gastroitestinal diagnostic in patients with nonspecific gastrointestinal symptomatology. In most of cases, for this patients, surgery is curative and definitive solution.

Gastric fundal heterotopic pancreas mimicking a gastrointestinal stromal tumour (GIST): a case report and a brief review

BACKGROUND

Heterotopic pancreas is a rare congenital condition characterised by pancreatic tissue lacking vascular or anatomic communication with the normal pancreas. Most cases of ectopic pancreas are asymptomatic. The preoperative diagnosis of this condition is difficult.

CASE PRESENTATION

A 50-year-old woman presented with dyspeptic symptoms of 4 years duration. Contrast enhanced CT (computed tomography) scan of abdomen suggested a gastrointestinal stromal tumour in the fundus of the stomach. The patient underwent laparoscopy assisted resection and subsequent histology revealed ectopic pancreatic tissue.

CONCLUSION

Although heterotopic pancreas is a rare lesion diagnosed on histology, it should be considered in the differential diagnosis of gastric mass lesions and in patients presenting with vague upper gastrointestinal symptoms.

Heterotopic pancreas of the jejunum: associations between CT and pathology features

PURPOSE

To investigate the computed tomography (CT) features of heterotopic pancreas of the jejunum (HPJ) and to assess their associations with HPJ pathology features.

METHODS

In this retrospective series analysis, two radiologists reviewed the CT images of 17 patients with surgically proven HPJ in order to determine in consensus the location, long diameter, margin, shape, contour, and growth pattern of the lesions, the presence of a duct-like structure, the lesion enhancement patterns, including the homogeneity, and the degree of contrast enhancement compared with that of the main pancreas. The pathology features of the surgical specimens were reviewed and their associations with the CT features were assessed.

RESULTS

On CT, the HPJs typically appeared as a small (<3 cm), well-defined, ovoid or flat-shaped mass in the proximal jejunum with multiple and tiny lobulations. The growth pattern varied and the duct-like structure was rarely visible. The HPJs mostly appeared to be homogeneous and exhibited hyper- or isoattenuation compared to the main pancreas in the arterial and portal phases. However, these enhancement patterns varied slightly depending on the microscopic composition of the lesions (i.e., acinar vs. ductal predominance). Most HPJs comprised histologically of large acini, some ducts, and small islet cells, and had ductal communication with the jejunum.

CONCLUSIONS

HPJs typically manifested as small, well-defined, ovoid or flat-shaped, homogeneous, and well-enhancing masses with a microlobulated contour in the proximal jejunum on CT, and their enhancement patterns associated with their microscopic composition. The pathology features of HPJs generally mimic those of the normal pancreas.

Hepatolithiasis associated with intrahepatic heterotopic pancreas: a case report and literature review

Abstract

Intrahepatic heterotopic pancreas is rarely reported in the literature. Here, we report a case of a 39-year-old male with intrahepatic heterotopic pancreas associated with primary cholesterol hepatolithiasis. Computed tomography (CT) scans revealed multiple cholesterol stones in intrahepatic bile ducts of the left lobe concomitant with intrahepatic cholangiectases. These observations were confirmed by magnetic resonance cholangiopaneretography (MRCP). The patient underwent transabdominal left hepatic lobectomy. Postoperative histological examination of the resected specimen showed pancreatic tissues distributed along the wall of the bile duct and composed of acinar cells and duct elements without islets of Langerhans, therefore strongly suggesting that the heterotopic pancreas occurred in response to chronic injury due to the primary cholesterol hepatolithiasis and was derived from the biliary epithelial cells.

Virtual Slides

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1461819267158980.

Endosonographic features of histologically proven gastric ectopic pancreas

Gastric ectopic pancreas is an uncommon developmental anomaly and its histological diagnosis is usually difficult by using a conventional biopsy forceps. In the literature, most cases of gastric ectopic pancreas were usually diagnosed by gross pattern during endoscopic examination or features of endoscopic ultrasound. In contrast, this disease was seldom diagnosed by histology in clinical practice. Although the typical endoscopic ultrasonographic features of ectopic pancreas include heterogeneous echogenicity, indistinct borders, and a location within 2 or more layers, it can also exhibit hypoechoic homogeneous echogenicity and a distinct border within the fourth sonographic layer (muscularis propria) similar to the endoscopic ultrasonographic features of gastrointestinal stromal tumors. In our study, we found that 53% of gastric ectopic pancreas originated within the fourth sonographic layer, demonstrating hypoechoic, homogeneous echogenicity, and distinct borders. Therefore, recognizing endoscopic ultrasonographic features, combining with deep biopsy, endoscopic ultrasound-guided fine needle aspiration/core needle biopsy can prevent conducting unnecessary resection. Surgical resection is the mainstay treatment for symptomatic gastric ectopic pancreas, but endoscopic resection using endoscopic mucosal resection or endoscopic submucosal dissection technique provides an alternative method of removing superficial-type and deep-type gastric ectopic pancreas.

Heterotopic pancreas: a rare cause of ileo-ileal intussusception

BACKGROUND

Heterotopic pancreas is a rare developmental anomaly defined as pancreatic tissue found on ectopic sites without contiguity with the main pancreas. An isolated heterotopic pancreas as a cause of bowel intussusception is extremely rare.

CASE REPORT

A case of 47-year old male with multiple episodes of melena, constipation and abdominal pain for one year duration is presented. CT eneterography revealed a large circumferential lesion involving the terminal ileum that acted as a leading point to an ileo-ileal intussusception. The resection of the lesion and related bowel segment was carried out. The histopathological examination confirmed the excised lesion as a heterotopic pancreatic tissue.

CONCLUSIONS

Though a rare entity, heterotopic pancreas should be considered in the differential diagnosis of bowel intussusception.

Ectopic tissue consisting of a mixture of glandular gastric, intestinal, and exocrine pancreatic tissue in the forestomach of a rat

The development of ectopic gastric, intestinal, or pancreatic tissue in the gastrointestinal tract is extremely rare in rats, although it is fairly common in humans. In this report, we describe an unusual case in which a mixture of different types of ectopic tissue was found in the forestomach of a rat. A solitary white nodular/polypoid structure, which measured 5 mm in size, was detected on the luminal surface of the greater curvature of the forestomach in an 8-week-old female Crl:CD(SD) rat. A histological examination revealed that the lesion contained ectopic glandular gastric tissue, including gastric surface mucous cells, parietal cells, and pyloric gland cells, which was confirmed by immunohistochemistry. Moreover, the lesion also contained villin-positive columnar intestinal absorptive cells and chymotrypsin-positive pancreatic exocrine tissue. To the best of our knowledge, this is the first study to detect a mixture of ectopic glandular gastric, intestinal, and exocrine pancreatic tissue in a rat.

Ectopic pancreas in upper gastrointestinal tract: MRI findings with emphasis on differentiation from submucosal tumor

BACKGROUND

Ectopic pancreas can frequently be mistaken for other submucosal masses. Ectopic pancreas may follow the signal intensity of mother pancreas on various magnetic resonance (MR) sequences, which might be helpful for differentiation between ectopic pancreas and other submucosal tumors in upper gastrointestinal (UGI) tract.

PURPOSE

To evaluate the value of MR imaging (MRI) in differentiating ectopic pancreases from submucosal tumors in UGI tract.

MATERIAL AND METHODS

Fifteen patients with ectopic pancreas and 26 patients with UGI submucosal tumors were included. All patients underwent abdominal MRI with diffusion-weighted imaging (DWI) and gadoxetic acid-enhanced MRI. Qualitative (location, contour, growth pattern, lesion border, and presence of intralesional cystic portion and duct-like structure) and quantitative (long diameter [LD], short diameter [SD], LD/SD ratio, signal intensities and apparent diffusion coefficients [ADC], and signal intensity - and ADC ratios of UGI submucosal lesions to pancreas) parameters were compared between ectopic pancreases and UGI submucosal tumors using Fisher's exact test, the Mann-Whitney U test, and receiver-operating characteristic (ROC) analysis.

RESULTS

Duodenum was the most common location for ectopic pancreas (12/15, 79.9%), and the gastric body for UGI submucosal tumors (15/26, 57.7%) (P = 0.005). Round shape was an imaging feature more common in UGI submucosal tumors (12/26, 46.2%) than in ectopic pancreas (1/15, 6.7%; P = 0.021). On all of the various pulse sequences of MR images, ectopic pancreas showed isointensity comparable to that of pancreas more frequently than did sequences of UGI submucosal tumors (P < 0.01).The means (0.95 ± 0.09, 0.99 ± 0.06, 1.07 ± 0.08) of the signal intensity ratio of ectopic pancreas to pancreas on fat-suppressed unenhanced T1-weighted, arterial, and portal phase images were significantly higher than those (0.60 ± 0.09, 0.62 ± 0.28, 0.86 ± 0.27) of UGI submucosal tumors (P < 0.05). In contrast, the means (1.05 ± 0.12, 0.93 ± 0.18) of the signal intensity ratios of ectopic pancreas on T2-weighted images and DW images (b = 800 s/mm(2)) were significantly lower than those (1.82 ± 0.39, 2.35 ± 0.94) of UGI submucosal tumors (P < 0.001). On ROC analysis, if absolute value of difference between 1.0 and signal intensity ratio of submucosal lesions to the pancreas on T1-weighted images is <0.21, the sensitivity and specificity reach 100.0% for diagnosis ectopic pancreas from submucosal tumors.

CONCLUSION

Abdominal MRI with DWI can be a valuable tool for differentiating ectopic pancreases from UGI submucosal tumors.

Ectopic pancreas: a diagnostic dilemma

An ectopic pancreas is defined as pancreatic tissue lacking vascular or anatomic communication with the normal body of the pancreas. It is rarely symptomatic as it is found incidentally at laparotomy most of the time. Despite advances in diagnostic modalities, it still remains a challenge to the clinician to differentiate it from a neoplasm. It is prudent to differentiate it from neoplastic etiologies, as simple surgical excision can potentially be curative. We discuss the presentation, diagnosis, and treatment of an interesting case of ectopic pancreas presenting as a gastric antral tumor.

Heterotopic pancreas of the gallbladder associated with segmental adenomyomatosis of the gallbladder

Heterotopic pancreas in the gallbladder is extremely rare and usually incidentally discovered at the pathologic examination followed by cholecystectomy for symptomatic gallbladder disease. Up to the presents, only about 30 cases have been reported. We report the case of a 36-year-old female who presented with symptoms of cholecystitis. The histological analysis followed by cholecystectomy revealed heterotopic pancreas of the cystic duct.

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.

Upper gastrointestinal tract heterotopic pancreas: findings from CT and endoscopic imaging with histopathologic correlation

OBJECTIVE

To evaluate and describe computed tomographic (CT) and endoscopic (ES) imaging findings in patients with pathologically confirmed upper gastrointestinal (GI) tract heterotopic pancreas (HP).

METHODS

Findings from imaging examinations in 11 patients with pathologically confirmed HP were retrospectively reviewed (CT images obtained from 11 patients and ES images from 6 patients were available for review). Two radiologists evaluated lesion location, size, shape and border as well as growth pattern, enhancement pattern, enhancement grade and number of tumors. The presence of surface dimpling, prominent enhancement of overlying mucosa, and low intralesional attenuation were also evaluated.

RESULTS

HP in the upper GI tract showed typical features in CT imaging: submucosal masses, ill-defined borders, endoluminal growth patterns, bright enhancement similar to the normal pancreas, surface dimpling and low intralesional attenuation. Endoscopic photographs manifested an endoluminal, ill-defined, submucosal mass in the upper GI tract wall, typically with central umbilication. The LD (long diameter)/SD (short diameter) ratios were found to be significantly different between HP in the stomach and HP in the duodenum (P<.05 for each finding). In addition, HP in the duodenum tended to be small and round.

CONCLUSIONS

HP exhibits typical pancreatic pathologic features. Images showed characteristic features in CT imaging: submucosal masses, ill-defined lesions with an endoluminal growth pattern, bright enhancement similar to the normal pancreas, surface dimpling and low intralesional attenuation. ES imaging showed an endoluminal, ill-defined, submucosal mass, typically with central umbilication.

Partial gastric outlet obstruction caused by a huge submucosal tumor originating in the heterotopic pancreas

A 21-year-old woman presented gastrointestinal manifestation showing intermittent abdominal pain, nausea, and vomiting. An upper endoscopic examination showed round, elevated mucosa at the antrum of the stomach anterior wall. After CT scanning, a huge degenerated gastrointestinal stromal tumor was suspected. Subtotal gastrectomy with Billroth II anastomosis was performed. Histologically, pseudocystic degeneration of the heterotopic pancreas was confirmed. The patient showed eventful postoperative course except temporary dilated gastric emptying. The patient is doing well without any abnormal symptom at 8-month follow-up. This report is a rare case of gastric outlet obstruction caused by a pseudocyst originating from a heterotopic pancreas in the gastric antrum.

Analysis of 151 consecutive gastric submucosal tumors according to tumor location

BACKGROUND

The aim of the present study was to evaluate the histopathological characteristics of gastric submucosal tumors (SMTs) according to their location.

METHODS

A retrospective analysis of a prospective database of 151 consecutive patients who underwent surgery for gastric SMTs between 2001 and 2009 was performed.

RESULTS

Of 151 gastric SMTs, 100 (66.2%) were gastrointestinal stromal tumors, 21 (13.9%) were leiomyomas, and 30 (19.9%) were other benign tumors. Leiomyoma was the most common neoplasm at the cardia (55.2%; P < 0.05), and the incidence of endophytic cardia tumors was higher compared with other locations (65.5%; P < 0.05). SMTs located at the cardia were significantly smaller than those found in the upper third (2.6 ± 1.0 vs. 4.1 ± 3.0; P < 0.05) and middle third (2.6 ± 1.0 vs. 3.9 ± 3.3; P < 0.05) of the stomach.

CONCLUSIONS

The characteristics of gastric SMTs located at the cardia differ significantly from those of gastric SMTs located in other regions of the stomach. These findings suggest that treatment strategy should be tailored by the location of tumors.

Pancreatic heterotopia of the duodenum: anatomic anomaly or clinical challenge?

INTRODUCTION

Pancreatic heterotopia (PH) is a common congenital anomaly and can occur anywhere in the gastrointestinal tract (GIT). In most cases, these heterotopias are asymptomatic and are only incidentally detected upon pathohistological examination or autopsy. We analyzed our cases of duodenal PH with respect to their clinical relevance and impact.

MATERIALS AND METHODS

Our prospectively collected pancreatic database was retrospectively analyzed. Thirty-four cases of duodenal PH were found. Specimens were reviewed by a GI pathologist. Classification was performed according to Heinrich (Type I acini, ducts, and islet cells; Type II acini and ducts; Type III only ducts).

RESULTS

From January 2000 to June 2009, we performed 534 pancreatic head resections. Thirty-two patients (6.0%) were found to have duodenal PH. Indications for pancreatic resections (pylorus-preserving pancreaticoduodenectomy, n = 26; Whipple, n = 6) were as follows: chronic pancreatitis, n = 16; malignancies, n = 9; cystic neoplasms, n = 5; and neuroendocrine neoplasms, n = 2. PH was also detected after two partial duodenal resections. In total, two cases of duodenal PH were found to be symptomatic. According to Heinrich, the following types were found: Type I, n = 12; Type II, n = 17; and Type III, n = 5 (total n = 34).

CONCLUSIONS

PH is rare and in most cases detected incidentally during pathohistological examination. However, in two of our patients, surgery was performed due to symptoms. Therefore, in patients with unclear pancreatoduodenal lesions, PH should be considered as a possible diagnosis. Resection is indicated for symptomatic cases.

[Bile duct dilatation associated with pancreatic heterotopia: a case report]

Pancreatic heterotopia or aberrant pancreas is a rare congenital anomaly, usually asymptomatic. Its diagnosis is difficult. We report an original observation in an 8-month-old infant, operated in the neonatal period for esophageal atresia type III in the context of VACTERL syndrome, cystic dilatation of the bile duct, and pancreatic heterotopia.

Pancreatic rest resection using band ligation snare polypectomy

BACKGROUND

Although pancreatic rests have characteristic endoscopic features, confirming a histological diagnosis may be desirable to exclude other significant pathology.

AIMS

The aim of this study was to assess the efficacy and safety of endoscopic band ligation snare polypectomy (EBLSP) for removal of suspected pancreatic rests and to compare the diagnostic yield to other endoscopic tissue sampling methods.

METHODS

An electronic endoscopic report database was searched for patients referred for evaluation of incidentally found gastric antral subepithelial lesions. Tissue sampling technique, pathology, and complications were recorded.

RESULTS

Removal of suspected pancreatic rests with EBLSP was successful in all 21 cases without complications. Nineteen of 21 (90%) who underwent EBLSP had a histological diagnosis of heterotopic pancreas compared with 5 of 14 (36%) who underwent tissue sampling with biopsy and/or snare (P = 0.001). The endoscopic characteristics of the histology proven pancreatic rests were an antral subepithelial mass with central umbilication measuring 6-10 mm in diameter and located 2-6 cm from the pylorus in the 3-7 o'clock position.

CONCLUSIONS

Endoscopic band ligation snare polypectomy resection of gastric antral lesions suspected to be pancreatic rests had a diagnostic yield superior to standard biopsy forceps and snare polypectomy techniques. However, because all pathologically confirmed pancreatic rests had typical endoscopic appearances of pancreatic rests, it may not be necessary to obtain histologic diagnosis for every suspected gastric antral heterotopic pancreas.

Heterotopia pancreática: análise clínico-patológica de 18 doentes

OBJETIVO: Analisar as características clínico-patológicas do tecido pancreático heterotópico em órgãos digestivos abdominais. MÉTODOS: Realizamos estudo retrospectivo analisando 18 portadores de pâncreas heterotópico diagnosticados histologicamente. Seus dados clínicos e histopatológicos foram revistos. O tecido pancreático heterotópico foi classificado em três modelos histológicos: tipo I constituído por três componentes do pâncreas normal (ácinos, ductos e ilhotas), tipo II com dois componentes e tipo três com somente um componente. RESULTADOS: A média de idade foi de 52,7 anos, variando de 34 a 73 anos, com nove homens e nove mulheres. Sintomas foram observados em somente quatro doentes, sendo suas lesôes diagnosticadas por gastroscopia. Os 14 restantes eram assintomáticos e suas anomalias descobertas acidentalmente. A maioria das lesões situava-se no trato superior: sete (38,9%) no estômago, seis (33,3%) no duodeno e três (16,6%) no jejuno. A heterotopia localizou-se preferencialmente na submucosa (83,3%), mas também foi observada na muscular própria e na sub-serosa. Em sete (38,9%) espécimes todos os componentes pancreáticos foram constatados (tipo I), em oito (44,4%) estavam presentes glândulas exócrinas e ductos excretores (tipo II) e em três (16,7%) somente o tecido exócrino foi observado (tipo III). CONCLUSÃO: A heterotopia pancreática é rara. Doentes com ectopia pancreática diagnosticadas pelo estudo patológico, assintomáticos ou com sintomas discretos devem permanecer em observação. As lesões detectadas acidentalmente durante procedimentos cirúrgicos necessitam ser removidas por procedimentos conservadores.

Endoscopic ultrasound in combination with endoscopic mucosal resection/endoscopic submucosal dissection for diagnosis and treatment of heterotopic pancreas

AIM: To investigate the use of endoscopic ultrasound in combination with endoscopic mucosal resection (EMR)/endoscopic submucosal dissection (ESD) for the diagnosis and treatment of heterotopic pancreas to improve the diagnosis of gastric heterotopic pancreas.

METHODS: The endoscopic and clinicopathologic data for 23 patients with suspected heterotopic pancreas who underwent EMR or ESD from September 2008 to February 2010 at our hospital were retrospectively analyzed. All tissue specimens underwent hematoxylin-eosin staining and observed by optical light microscopy.

RESULTS: Of all the 23 patients included, 19 underwent EMR and 4 underwent ESD; 13 were diagnosed with heterotopic pancreas by postoperative pathological examination and 10 were misdiagnosed.

CONCLUSION: Endoscopic ultrasound in combination with EMR or ESD can improve the diagnosis of gastric heterotopic pancreas.

[Tumor of the esophoagocardiac junction]

The presence of heterotopic pancreatic tissue in the gastroesophageal junction is a very rare entity. An exact preoperative diagnosis is only rarely possible despite all available diagnostic procedures. We report on the case of a submucous tumor of the gastroesophageal junction which became symptomatic due to reflux problems and was successfully removed by endoscope-assisted laparoscopic resection.

Invasive ductal adenocarcinoma arising from pancreatic heterotopia in rectum: case report and review of literature

Pancreatic heterotopia has been described at several abdominal and intrathoracic locations, most commonly in the stomach and upper part of the small intestine. Its occurrence in the rectum is unusual, and malignant transformation in the rectum has not been reported. We report a case of ductal adenocarcinoma arising in a rectal pancreatic heterotopia in a 42-year-old woman with delayed local recurrence. The tumor was composed of well to moderately differentiated ductal adenocarcinoma infiltrating through the full thickness of the anorectal wall with extension into the vaginal septum. A focus of ectopic pancreas consisting of exocrine acini and small ducts adjacent to the tumor with some ducts showing mild to severe dysplasia reminiscent of pancreatic intraepithelial neoplasia was also observed. Although our literature search found 31 documented reports of tumors arising in the heterotopic pancreas, the present case is the first case of ductal adenocarcinoma arising in a focus of pancreatic heterotopia in the rectum.

[Heterotopic pancreatic tissue in the bifurcation of the bile duct : Rare diagnosis mimicking a Klatskin tumour]

Heterotopic tissue of the pancreas can be found in 1-2% of autopsies. The main locations are stomach, duodenum, jejunum, Meckel's diverticulum, and ileum. Less frequently it is observed in the liver, gallbladder, common bile duct, and papilla of Vateri. We report the first case of heterotopic pancreatic tissue in the bifurcation of the bile duct mimicking a Klatskin's tumour. The case is discussed based on the current literature.

[Heterotopic pancreatic tissue in the bifurcation of the bile duct : Rare diagnosis mimicking a Klatskin tumour]

Heterotopic tissue of the pancreas can be found in 1-2% of autopsies. The main locations are stomach, duodenum, jejunum, Meckel's diverticulum, and ileum. Less frequently it is observed in the liver, gallbladder, common bile duct, and papilla of Vateri. We report the first case of heterotopic pancreatic tissue in the bifurcation of the bile duct mimicking a Klatskin's tumour. The case is discussed based on the current literature.

Pseudoneoplasms of the gastrointestinal tract

CONTEXT

The pathologist plays the leading role in distinguishing pseudoneoplasms from truly neoplastic lesions in the gastrointestinal tract.

OBJECTIVE

This review was conducted to heighten awareness of pseudoneoplasms, to help differentiate among the various types of pseudoneoplasms, and to help distinguish pseudoneoplasms from malignancies.

DATA SOURCES

This review is based on the medical literature on pseudoneoplasms in MEDLINE and the authors' own experiences. Reference lists of retrieved articles were also reviewed to identify additional articles.

CONCLUSIONS

A classification of pseudoneoplasms, according to the mechanism of injury to the gastrointestinal tract, morphologic patterns, and heterotopia, may be useful in providing a diagnostic framework in which ancillary techniques often have a diagnostic role. Several pseudoneoplasms may be closely associated with true neoplasms (eg, malakoplakia, prolapsetype lesions) because of the nonspecific nature of the response of the intestine to injury.

A clinical and radiologic review of uncommon types and causes of pancreatitis

Acute pancreatitis is one of the most common conditions for which emergent imaging is indicated. Alcohol consumption and cholelithiasis are the most common causes of acute pancreatitis in adults, whereas the majority of cases in children are idiopathic or secondary to trauma. A wide variety of structural and biochemical abnormalities may also cause pancreatitis. Although in some cases it is difficult to identify the specific cause of the disease radiologically, certain uncommon types of acute or chronic pancreatitis may have unique imaging features that can help the radiologist make an accurate diagnosis. These unusual types include autoimmune pancreatitis, groove pancreatitis, tropical pancreatitis, hereditary pancreatitis, and pancreatitis in ectopic or heterotopic pancreatic tissue. Pancreatitis may occasionally be seen in association with cystic fibrosis or pancreas divisum, or secondary to worm infestation of the pancreaticobiliary tree (eg, by Ascaris lumbricoides). In addition, primary pancreatic and duodenal masses may occasionally manifest as acute or recurrent acute pancreatitis. Knowledge of the classic imaging findings of these entities allows prompt recognition of the relevant pathologic condition, thereby preventing misdiagnosis and subsequent inappropriate or delayed management.

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue. Treatment of heterotopic pancreas may include expectant observation, endoscopic resection or surgery. The aim of this report was to describe the technique of ligation-assisted endoscopic mucosal resection (EMR) for resection of heterotopic pancreas of the stomach. Two patients (both female, mean age 32 years) were referred for management of gastric subepithelial tumors. Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa. Band ligation-assisted EMR was performed in both cases without complications. Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa. Margins were free of pancreatic tissue. Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue. Treatment of heterotopic pancreas may include expectant observation, endoscopic resection or surgery. The aim of this report was to describe the technique of ligation-assisted endoscopic mucosal resection (EMR) for resection of heterotopic pancreas of the stomach. Two patients (both female, mean age 32 years) were referred for management of gastric subepithelial tumors. Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa. Band ligation-assisted EMR was performed in both cases without complications. Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa. Margins were free of pancreatic tissue. Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.

Duodenal heterotopic pancreas in a child

BACKGROUND

Heterotopic pancreas is characterized by pancreatic tissue outside the pancreatic bed. However, duodenal heterotopic pancreas in children is rarely reported so far. We describe herein duodenal heterotopic pancreas in a child who suffered from chronic abdominal pain.

METHODS

An 8-year-old boy presented with upper abdominal pain and intermittent vomiting, without a history of melena, hematochezia, hematemesis, clay-colored stools, jaundice, hepatitis or dyscrasia. No specific medication or change in position relieved the pain. Based on the elevated serum amylase levels, and the findings of CT, barium meal X-ray examination, magnetic resonance imaging, and upper gastrointestinal endoscopy, a duodenal mass was diagnosed initiatively. Intraoperative frozen section analysis was performed for the diagnosis. The mass was dissected.

RESULTS

Intraoperative frozen section analysis and routine pathological examination confirmed the diagnosis of duodenal heterotopic pancreas. The patient had an uneventful recovery and remained asymptomatic postoperatively during a follow-up period of 16 months.

CONCLUSIONS

Heterotopic pancreas should be considered in children with a duodenal mass and abdominal pain. Intraoperative frozen section analysis is helpful in the diagnosis of the disease. Surgical treatment of the lesion should be performed to prevent bleeding, ulceration, outlet obstruction or malignant degeneration.