Giant Heterotopic Pancreas Presenting with Massive Upper Gastrointestinal Bleeding

Abstract

Heterotopic pancreas, or pancreatic rest, refers to extra-pancreatic tissue without an obvious vascular or anatomic connection with the pancreas. Although common in the upper gastrointestinal tract, heterotopic pancreatic tissue rarely causes symptoms. We describe a patient who presented with massive hematochezia found to have a giant heterotopic pancreas in the duodenum. A 59 year-old female presented to the emergency department of our medical center complaining of melena and upper abdominal pain. There was no aspirin or NSAID use. On physical examination, she was tachycardic, orthostatic, pulse of 114 beats per minute and blood pressure 110/70 mmHg. The abdomen was soft and tender to palpation in the epigastric region. Initial laboratory testing revealed a hemoglobin of 9.7 g/dl. The patient underwent a computed tomographic (CT) scan of the abdomen to evaluate the abdominal pain and tenderness. A large soft tissue density was appreciated obstructing the lumen of the 2nd portion of the duodenum. Upper endoscopy revealed a large irregular mass occupying the second portion of the duodenum. The mass appeared to originate from the ampulla. Multiple biopsies were taken. Endoscopic ultrasound could not clarify the source of the mass. An FNA was performed with an Olympus 22 guage needle. Cytology results revealed “normal cells.” Due to persistent bleeding, the patient underwent surgical resection of the lesion, pancreaticoduodenectomy. Surgical pathology revealed that the lesion was 12.5 cm x 5.7cm x 8 cm composed of sheets of heterotopic pancreatic tissue, benign appearing. The patient recovered and remains well. Heterotopic pancreas is a rare entity, identified incidentally and warranting no intervention. However, our patient presents with a unique form of heterotopic pancreas not previously described. This case represents the largest heterotopic pancreas reported. In addition, the symptoms of massive upper gastrointestinal bleeding have not been previously described. Initial attempts at establishing the diagnosis including CT, endoscopic biopsy, and endoscopic ultrasound with biopsy were unsuccessful. Surgical excision was needed to establish the diagnosis and treat the persistent bleeding. Although rare, heterotopic pancreas should be considered in the differential diagnosis of masses causing upper gastrointestinal bleeding.