Heterotopic Pancreas Presenting as Hematemesis

Abstract

Introduction: Heterotopic pancreas is also known as an aberrant pancreas or accessory pancreas, is a scare congenital abnormality defined as the growth of pancreatic tissue outside of the pancreas with no anatomic or vascular connection with normal pancreatic tissue. Such tissue may occur throughout the Gastrointestinal (GI) tract but has a propensity to affect the stomach and the proximal small intestine. The majority of patients with pancreatic heterotopia are asymptomatic, but when symptoms occur they can present in a variety of ways. We report a case of a patient whose pancreatic rest presented as epigastric pain and was diagnosed by endoscopic biopsy after an episode of hematemesis. Case Presentation: The patient is a forty two year old female patient with a history of an ectopic pregnancy and ovarian cyst removal in 2011. She came to the primary care clinic to establish care in 2012, at which she complained of epigastric pain radiating to the back for years, no relationship to food. She denied any nausea, vomiting, weight loss, changes in appetite, melena or hematochezia. Four months later, she presented to the Emergency Room complaining of two episodes of bloody emesis with epigastric pain. Her vital signs: temperature 98.7F, HR: 85 and BP110/78 mmHg. She was well appearing, no epigastric tenderness, no organomegaly appreciated. Laboratory results were significant for HCT = 10.8/33.3 MCV 81.7. Helicobacter pylori test was negative. Amylase, lipase and hepatic panel were normal. Abdominal Ultrasound was normal. The Patient had an endoscopy that revealed two antral polyps in the stomach that were biopsied. Colonoscopy showed Grade one hemorrhoids. Pathology report revealed Gastric Heterotopic pancreas without inflammation. Three months later, she had a follow up clinic visit and was asymptomatic. Discussion: Heterotopic pancreas can exist at any position in the abdominal cavity. It is usually found in the upper gastrointestinal tract, with >90% of the cases involving the stomach, duodenum or jejunum. The Incidence rate is 0.11% - 0.21%, and a male to female ratio 3:1. Diagnosis is often difficult and symptoms can mimic other GI pathologies and malignancies. The particular symptomatology that manifest is relative to the size and its location within the GI tract. Hematemesis is a rare presentation of heterotopic pancreatic tissue and it is vital that all clinicians be aware of this clinical entity to avoid misdiagnoses.