Diagnosis Of Heterotopic Pancreas Research Articles

Heterotopic Pancreas: Unusual Cause of Usual Diarrhoea.

Heterotopic pancreas (HP) also known as ectopic pancreas, pancreatic crest or accessory pancreas is the normal pancreatic tissue, found in a remote area other than its natural location, with no anatomic or vascular connection to main pancreatic tissue. It is a rare congenital anomaly and has been reported at many locations such as stomach (antrum) and small intestine. HP is usually an incidental finding and asymptomatic, however there are reports of pancreatitis, obstruction, perforation and malignant transformation as uncommon manifestations. Diagnosis of HP is primarily based on histological examination either by biopsy or surgical excision. Surgery is the standard treatment for symptomatic HP patients. Herein, we present a case of a 58-year-old female, who presented to us with intractable diarrhoea due to HP in the jejunum and underwent minimally invasive surgery for definitive diagnosis and treatment.

An Unusual Location for Pancreatic Heterotopia: The Gastroesophageal Junction

: Heterotopic pancreas (HP) is defined as pancreatic tissue found outside the pancreas. When symptoms appear, they are often due to inflammation, obstruction, and malignant transformation. The most common location is the stomach, especially the antrum. HP in the esophagus is uncommon, with only a handful of cases reported in pediatric patients. It rarely occurs in the adult population.We present an atypical case of HP at the gastroesophageal junction (GE) in a middleaged female. Case: A 59 year old African American female was referred for iron deficiency anemia. Patient had recurrent cough. She denied symptoms of dyspepsia. Physical exam was unremarkable. The white blood cell was 9.7 (3.8-10.6), blood Hg 11.9 g/dL, HCT 34.4% with an MCV of 77.8 L, and platelet count was 246. Stool occult testing negative. An esophagogastroduodenoscopy revealed a small, broad-based polyp about 3-4 mm in diameter without umbilication, or evidence of bleeding (Figure 1). It was glimpsed at the GE junction on introduction of the endoscope, and confirmed on a retroflexed view (Figure 2). A biopsy of the polyp was obtained with cold forceps, and sent for histopathologic examination which revealed focal pancreatic acinar cell metaplasia/heterotopia completely surrounded by gastric cardia-type mucosa with chronic active gastritis, acute cryptitis (Figure 3). There was no evidence of intestinal metaplasia or dysplasia, or esophageal squamous mucosa. Because the polyp was located at the GE junction, the origin could have been esophageal or gastric. However, because the surrounding tissue histologically was entirely gastric, a diagnosis of HP of the stomach at the GE junction was assigned. The patient had been asymptomatic and did not present with complications, a follow up plan for endoscopic surveillance was proposed.Figure 1Figure 2Figure 3Discussion: The incidence of HP cases has been reported to be 2 to 15%, with the majority found incidentally during surgery or post-mortem autopsies. Endoscopically, HPs grossly appear as firm white to yellow lobulated nodules and range in size almost 0.2 to 4 cm. Our case was unusual in that it did not have the characteristic umbilication, nor discoloration, but rather a nodular polypoid appearance, and was located not in the atrum or body, but at the GE junction. In a symptomatic patient, resection is performed after other causes are ruled out. In an asymptomatic patient, with benign gross and histological features, lesions are managed conservatively.

Laparoscopic Intraoperative Bariatric Surgery Finding of Heterotopic Pancreatic Tissue

Heterotopic pancreas is defined as pancreatic tissue found outside the usual anatomic or vascular continuity of the pancreas. Mostly discovered incidentally during autopsies in up to 14% of patients and only 0.2% of upper abdominal laparotomies, it remains a diagnostic challenge when discovered during bariatric surgery. Although, heterotopic pancreatic tissue is usually asymptomatic and benign, it behaves as normal pancreatic tissue and therefore pancreatitis, cysts, pseudocysts, and malignant transformation may be seen which can complicate the post-surgical period. In addition, complications of mass effect including gastric-outlet, bile-duct obstruction, bleeding from ulcerated mass, and intussusception have also been reported. We report two cases of incidental lesions found during laparoscopic bariatric surgery in the proximal jejunum that were removed intraoperatively and pathologic analysis revealed benign heterotopic pancreatic tissue. The first case was a 39-year-old female who presented for elective Roux-en-Y gastric bypass. During the laparoscopic intra-abdominal small bowel inspection, the surgeon noticed an approximately 12cm polypoid tumor located distal to the ligament of Treitz. An intraoperative endoscopy did not reveal any mucosal abnormalities up until the ligament of Treitz. Resection of the tumor was done and sent to Pathology for frozen section. The pathologist confirmed pancreatic cells with some ectopic glands, however malignancy was not ruled out. The gastric bypass procedure was aborted and resection of the small bowel lesion was done. Final pathologic diagnosis was consistent with benign heterotopic pancreas. The second case was a 47-year-old female who presented for elective Roux-en-Y gastric bypass. During the laparoscopic intra-abdominal small bowel inspection, the surgeon noticed a small bowel tumor approximately 35cm distal to the ligament of Treitz. The tumor was firm on laparoscopic instrument manipulation with a small fungating appearing lesion anteriorly, which was resected. Final pathologic diagnosis was consistent with submucosal heterotopic pancreas. Diagnosis of heterotopic pancreas, benign or malignant, is difficult solely based on laproscopic appearance, however it is imperative to consider in the differential diagnosis. More importantly, in bariatric patients undergoing anatomy-altering surgery (i.e. Roux-en-Y gastric bypass), such lesions while still amenable should be resected to avoid potential complications.Figure 1Figure 2

Endoscopic excavation for gastric heterotopic pancreas: an analysis of 42 cases from a tertiary center.

Because of the difficulty associated with making an accurate diagnosis of gastric heterotopic pancreas (HP) before surgery, surgical resection is usually performed in suspected cases. However, this is an invasive procedure and prone to certain surgical complications. This study was designed to evaluate the feasibility of endoscopic excavation for gastric HP, as well as the value of endoscopic ultrasonography (EUS) in diagnosing gastric HP. Between January 2007 and January 2013, 42 consecutive patients with gastric HP were enrolled in this retrospective study. Key steps: (1) Injection of a solution (100 ml saline + 2 ml indigo carmine + 1 ml epinephrine) into the submucosal layer after making several dots around the lesion; (2) Incision of the mucosa outside the marker dots with a needle-knife, and then circumferential excavation until complete resection of the lesion; (3) Closure of the artificial ulcer with several clips after tumor removal. In this study, 18 cases (42.9%) were suspected as gastric HP (assessed by two experienced endoscopists before endoscopic excavation), 8 (19.0%) were suspected as gastrointestinal stromal tumors, 7 (16.7%) as gastric polyp, and the remaining 9 cases (21.4%) were still unknown. The mean procedure duration was 28.6 min. En bloc resection by endoscopic excavation was achieved in 40 cases (95.2%), and no massive bleeding, delayed bleeding, perforation, or other severe complication occurred in these patients. Among the 42 lesions, a tube echo could be detected in 11 cases by EUS. Those 11 cases were diagnosed as gastric HP by histopathology. Endoscopic excavation appears to be a safe and feasible procedure for accurate histopathologic evaluation and curative treatment in gastric HP. Use of EUS has some value in the diagnosis of gastric HP before the procedure

Endoscopy and endoscopic ultrasonography for heterotopic pancreas in upper gastrointestinal tract

Objective To study the characteristics of heterotopic pancreas （HP） in upper gastrointestinal tract （UGIT） under endoscopy and endoscopic sonography （EUS）, and its endoscopic manage- ments. Methods Data of 67 patients with pathologically confirmed HP in our hospital from March 2004 to November 2009, including clinical and endoscopic manifestations and sequelae after endoscopic resection, were retrospectively studied. Results Heterotopic pancreas were most commonly found as a single lesion in gastric antrum （62/67, 92. 5% ） and in gastric angle and duodenum as well, which were characterized by protrusion, with intact mucous membrane and centrally umbilicated. Of the 67 patients, 59 underwent EUS before endoscopic resection. Findings were heterogeneous and mixed echogenic lesions with indistinct borders involving both the second and third layers of the gastrointestinal wall, sometimes even involving the first and fourth layers. Most lesions （n = 60） were removed by endoscopic mucosal resection （EMR） , with basal res- idues in 25 eases, in which fourth layer involvement was observed in 23 cases （92. 0% ）. Delayed bleeding occurred in 1 case at 3rd day after the procedure, and no other complications were observed. Complete re- moval was achieved in 8 cases （including one receiving EMR previously） with endoscopic submucosal dis- section （ESD） , and there was no such severe complications as perforation. Postoperative pathological exami- nations revealed that the consistent rate of preoperative diagnosis with EUS was 91.5% （54/59）. Conclu- sion Endoscopy combined with EUS is critical in diagnosis of HP in UGIT. EMR, especially with cap assistance, is the best method for those without involvement of muscularis propria, while ESD or endoscopic surveillance is a better alternative for those with 4th layer involvement. Key words: Pancreatic diseases ; Endoscopic uhrasonography ; EMR ; ESD

Heterotopic Pancreas within Meckel's Diverticulum with Obscure then Massive Gastrointestinal Bleeding in a 12-year-old Child: Case Report and Review of the Literature

We report a case of a 12-year-old boy with heterotopic pancreas (HP) located in a Meckel's diverticulum (MD) and presenting as obscure gastrointestinal (GI) bleeding. Upper GI endoscopy and colonoscopy did not reveal the source of the bleeding, however, capsule endoscopy revealed a space-occupying lesion in the ileum. The patient developed massive bleeding and an emergency exploratory laparotomy was performed. A congested MD was discovered 100 cm from the ileocaecal valve using intra-operative endoscopy; the ulcerated tip of the diverticulum appeared to be the source of the bleeding. The MD and adjacent ileal segment were resected and an end-to-end anastomosis performed. Subsequent pathological examination revealed an ileal MD with HP tissue within the submucosa. The patient remains well, 12 months after the operation, with no evidence of recurrent bleeding. This case suggests that HP should be considered as one possible cause of obscure GI bleeding in children and capsule endoscopy is a valuable adjuvant tool in the diagnosis of HP in children.

Cystic dystrophy in gastric heterotopic pancreas complicated by intracystic hemorrhage and fistulisation in the stomach – a pediatric case

Cystic dystrophy of the digestive wall, a rare but well-known complication of heterotopic pancreas when it is located in the duodenum, has been mainly described in adult series. Cystic dystrophy of the heterotopic pancreas within the gastric wall has been reported in only six adult cases. To our knowledge, no pediatric case has been described. We report a 15-year-old boy surgically treated for cystic dystrophy located in the antrum, complicated by an intracystic hemorrhage and fistulisation into the stomach. The diagnosis of heterotopic pancreas must be considered in case of submucosal cystic-gastric lesions, even in pediatric cases. Although the surgical approach is not systematic, it is recommended when cystic dystrophy is symptomatic (e.g., occlusion or hemorrhage).

Diagnosis and Treatment of Gastric Heterotopic Pancreas

Heterotopic pancreas (HP) in the stomach can be difficult to diagnose and there are many treatment options. The aim of this article is to review the contemporary diagnosis of and treatment options for HP in the stomach. We undertook a retrospective review of patients with the diagnosis heterotopic pancreas registered at St. Olavs University Hospital in Trondheim from 1990 to 2002. We report on clinical findings, provide a histological review, and summarize the literature with particular emphasis on the diagnosis and treatment of HP in the stomach. We found 32 cases, most of them in the stomach and the small intestine. Sixteen patients were symptomatic. A histological examination showed that most of the tumors were submucosal and had the appearance of normal pancreas tissue. Gastric HP is not an uncommon diagnosis compared with many other gastric tumors and should more often be considered as a differential diagnosis. Symptom correlation is not always easy to determine, but symptom relief after treatment is well established. An endoscopic ultrasound examination may help when screening patients for extended biopsy and in deciding on which type of operation is to be performed. When treated, minimally invasive techniques should be applied.

PANCREATIC HETEROTOPIA AND CYSTIC DYSTROPHY OF DUODENUM, AN UNCOMMON PATHOLOGY AND THE ROLE OF ENDOSCOPIC ULTRASOUND IN THE DIAGNOSIS

Pancreatic heterotopy, a rare entity, is defined as pancreatic tissue lying outside its normal location without anatomical or vascular connections with the pancreas proper. Cystic dystrophy is an uncommon and serious complication of heterotopic pancreas, usually in younger men. The mechanism by which cystic dystrophy develops is poorly understood. It is difficult to diagnose, as lesions deeper in the submucosa or the muscularis propria, are difficult to biopsy. We present an interesting and rare case of pancreatic heterotopia with cystic dystrophy of the duodenal wall, where endoscopic ultrasound clearly shows cystic changes in deeper layers of duodenum, later confirmed by surgery. Case: A 54-yr-old white male presented to the hospital after several bouts of abdominal pain. Prior to presentation, he experienced several episodes of nausea and vomiting. He also had lost approximately 15 lb over the past two months. Past history was significant for non-hodgkins lymphoma, which had been in remission for 6 years. During endoscopy, a sessile mucosal lesion with mass effect was visualized in the second part of the duodenum and biopsies were obtained. Pathology was negative for cancer, but did show edema and lymphangiectasia. Endoscopic ultrasound showed a 1 cm cystic lesion in the wall of duodenum at the second portion. A pancreas-preserving duodenectomy was performed. Duodenal specimens showed a cystic lesion in the wall of duodenum. The mucosa overlying the cyst showed a mix of acute and chronic inflammation of the lamiNaPropria. The cyst was located within the muscularis propria, which was hypertrophied. Focal areas showed an epithelial lining composed of columnar/cuboidal cells with basal nuclei and prominent brush border, suggestive of pancreatic ductal epithelium. Based on these findings, a diagnosis of heterotopic pancreas with cystic dystrophy of the duodenal wall was made. Discussion: Duodenal cystic dystrophy due to heterotopic pancreatic deposit is an uncommon pathology. In the past, it was extremely difficult to diagnose without surgery because there are no specific clinical signs. Our case demonstrates effective use of endoscopic ultrasound in precisely locating cysts in the duodenal wall when other imaging modalities, such as CT scan can not. We will present EUS images, histology slides and a detail discussion about heterotopic pancreatic cyst and the role of different diagnostic modalities.