Aberrant Pancreatic Tissue in the First Portion of the Duodenum

Abstract

The presence of pancreatic tissue in an aberrant location is being reported with increasing frequency and can no longer be considered a rare postmortem or surgical finding. Such tissue, moreover, is often responsible for symptoms, which are sometimes severe. A recent classic review and contribution to the subject from the Mayo Clinic lists 21 of 41 histologically authenticated cases as having been clinically significant (1). The formation of aberrant (accessory or heterotopic) pancreatic tissue is usually considered to be due to defective embryologic development. Horgan (2) believed that during early development the branching ducts of the body of the pancreas become engrafted on contiguous organs during the migration of the latter and before the coalescence of the primitive pancreatic anlagen, and that this graft is pulled off and forms an intramural mass. Warthin (3) held that the rudimentary pancreatic ducts penetrate the intestinal wall by lateral budding and are separated by longitudinal growth of the intestine. The possibility that the aberrant tissue is due to anaplasia of intestinal mucous membrane may also be mentioned, but only for the sake of completeness. The aberrant pancreatic tissue is usually in the form of a single firm nodule, measuring about 1.0 to 4.1 cm. in diameter. It is most commonly found beneath the mucous membrane and frequently infiltrates the muscle fibers. The nodule is usually sessile; it may be lobulated and present a granular surface. The appearance on cut section is glandular, and the color is white to yellow. Case Report T. B. S., a 24-year-old white male, was admitted to the hospital March 17, 1949, complaining of heartburn and dull epigastric pain occurring shortly after meals. In 1943, while in the Army in North Africa, he had been hospitalized for three weeks, following constipation for one week and an episode of severe vomiting. Subsequently the present symptoms developed. The patient complained of the frequent passage of gas, orally and rectally, especially after eating fried and greasy foods. He was taking milk of magnesia after each meal to relieve his “indigestion” and insure a daily bowel movement. In 1945, the patient had been given a 60 per cent disability discharge from the Army for hepatitis, psychoneurosis, and right renal stones. Cystoscopy had since been done at two hospitals, and there is a possibility that stones were removed. Two weeks before admission a diagnosis of polyp of the first part of the duodenum was made on two different occasions, in another hospital. The patient appeared well nourished and, except for slight epigastric tenderness, physical examination was not significant. The laboratory findings, including liver function tests and gastric analysis, were within normal limits. The blood pressure was 140/88. No tests were done for pancreatic function.