Heterotopic Pancreatic Tissue Research Articles

Cystic dystrophy in heterotopic pancreas.

Cystic dystrophy in heterotopic pancreas, or paraduodenal pancreatitis, is a rare and complicated presentation involving heterotopic pancreatic tissue in the duodenal wall. This condition is present in 5% of the general population but disease mainly affects middle-aged alcoholic-smoking men with chronic pancreatitis (CP). It may be purely duodenal or segmental (pancreatico-duodenopathy). Its pathophysiology arises from alcohol toxicity with obstruction of small ducts of heterotopic pancreatic tissue present in the duodenal wall and the pancreatic-duodenal sulcus, leading to repeated episodes of pancreatitis. The symptomatology includes episodes of acute pancreatitis, weight loss, and vomiting due to duodenal obstruction. Imaging shows thickening of the wall of the second portion of the duodenum with multiple small cysts. A stepwise therapeutic approach is preferred. Conservative medical treatment is favored in first intention (analgesics, continuous enteral feeding, somatostatin analogues), which allows complete symptomatic regression in 57% of cases associated with a 5% rate of complications (arterial thrombosis and diabetes). Endoscopic treatment may also be associated with conservative measures. Surgery achieves a complete regression of symptoms in 79% of cases but with a 20% rate of complications. Surgery is indicated in case of therapeutic failure or in case of doubt about a malignant tumor. Pancreaticoduodenectomy and duodenal resection with pancreatic preservation (PPDR) seem to be the most effective treatments. PPDR has also been proposed as a first-line treatment for purely duodenal location of paraduodenal pancreatitis, thereby preventing progression to an extended segmental form.

Localization and Laparoscopic Excision of Gastric Heterotopic Pancreas in a Child by Endoscopic SPOT® Tattooing

Heterotopic pancreas (HP) is defined as pancreatic tissue lacking vascular or anatomic connection with the normal pancreas. Surgical resection is often indicated for symptomatic gastric HP. However, intraoperative identification of gastric HP is often difficult during laparoscopic surgery. Herein, we describe a patient with gastric HP, which was marked with SPOT® dye (GI Supply, Camp Hill, PA, USA). The dye was seen clearly laparoscopically facilitating total excision of the lesion. The final pathology report confirmed the presence of heterotopic pancreatic tissue including pancreatic acini, small pancreatic ducts tissue with islets of Langerhans in the deep gastric submucosal area. There were no postoperative complications, and the patient was symptom-free. To the best of our knowledge, this was the first case report in the literature in which endoscopic tattooing of gastric HP before laparoscopic resection was performed. This method of localization was simple and reliable in children.

Aberrant pancreas adenocarcinoma in the stomach: A case report and literature review.

Aberrant pancreatic tissue in the gastrointestinal tract is a relatively common finding. However, malignant transformation is extremely rare. Herein, we report a case of ectopic pancreatic ductal adenocarcinoma in the stomach wall. A 38 year old male presented with nausea, bloating, abdominal distention and weight loss for 4 months. Endoscopy of upper gastrointestinal tract was performed twice with 2 months interval and a stenotic pyloric part was observed with a suspected submucosal lesion. It was sampled both times, however the pathology findings of the mucosal biopsies were unremarkable with no identifiable neoplastic structures. CT scan and MRI was performed and showed a thickened pyloric wall with a submucosal lesion 15 × 15 mm in diameter. Blood levels of tumor markers carcinoembrionic antigen and carbohydrate antigen 19-9 were within a normal range. Pyloric stenosis progressed and the patient underwent a Billroth type I distal gastric resection with D2 lymphadenectomy. Pathologic examination revealed a well differentiated ductal adenocarcinoma arising in the heterotopic pancreatic tissue (Heinrich type III). The resection margins and lymph nodes were free of tumor. The patient received adjuvant chemotherapy with 6 courses of XELOX. No disease recurrence is reported in 12 months follow-up. Aberrant pancreatic ductal adenocarcinoma in the stomach is a rare finding, however this pathology should be included in the differential diagnosis of gastric submucosal lesion causing pyloric stenosis.

Heterotopic Pancreas in the Esophagus: What Do We Know?—A Review of the Literature

Heterotopic pancreatic tissue is a rare phenomenon, which may occur in locations outside of the pancreas within the gastrointestinal tract. Of these locations, involvement in the esophagus is quite rare. It is paramount to improve our understanding regarding heterotopic pancreas, as some lesions may carry malignant potential. With this article, we present a case of heterotopic pancreas in the distal esophagus and review the current literature.

[Radiologic Diagnosis of Gastrointestinal Bleeding].

Gastrointestinal (GI) bleeding is not a single disease but a symptom and clinical manifestation of a broad spectrum of conditions in the GI tract. According to its clinical presentation, GI bleeding can be classified into overt, occult, and obscure types. Additionally, it can be divided into upper and lower GI bleeding based on the Treitz ligament. Variable disease entities, including vascular lesions, polyps, neoplasms, inflammation such as Crohn's disease, and heterotopic pancreatic or gastric tissue, can cause GI bleeding. CT and conventional angiographies and nuclear scintigraphy are all radiologic imaging modalities that can be used to evaluate overt bleeding. For the work-up of occult GI bleeding, CT enterography (CTE) can be the first imaging modality. For CTE, an adequate bowel distention is critical for obtaining acceptable diagnostic performance as well as minimizing false positives and negatives. Meckel's scintigraphy can be complementarily useful in cases where the diagnosis of CTE is suboptimal. For the evaluation of obscured GI bleeding, various imaging modalities can be used based on clinical status and providers' preferences.

Heterotopic pancreatic tissue in gall bladder incidentally detected in a case of acute cholecystitis: A case report and review of the literature

Heterotopic pancreatic tissue in the gall bladder is a very uncommon lesion. In most cases, it is an incidental finding. The placement of pancreatic tissue in an organ outside the pancreas is called pancreatic heterotopy. Heterotopic pancreas is commonly found in the stomach, small intestine, and Meckel’s diverticulum. It has rarely been seen in the gall bladder, bile duct, splenic hilum, or liver. We present a case of incidentally discovered heterotopic pancreatic tissue in a case of acute cholecystitis in a 63-years-old lady having a history of pain in the right hypochondriac region.

HISTOGENESIS OF HUMAN FETAL STOMACH AT VARIOUS GESTATIONAL AGES – AN OBSERVATIONAL STUDY

Objective: Knowledge on timelines of structural and histological development of fetal stomach helps in the diagnosis of abnormalities (duplication cyst of the pylorus, heterotopic pancreatic tissue, etc.,) and weighing interventions as an option. The present study was undertaken to establish the timelines of the developmental process of stomach (e.g., appearance of curvatures, gastric pit, gastric glands, and various cell types) correlating with the gestational age. Methods: Fifty normal, aborted and unclaimed fetuses were obtained from local private and government hospitals observing all formalities. The tissues of 3–5 mm thickness were taken and preserved in 10% formalin for 72 h, followed by tissue processing and staining with hematoxylin eosin and periodic acid Schiff and observations were made under microscope. Results: Lesser and greater curvatures appeared in the first trimester. All the four layers and gastric pits were observed at 16th week, cuboidal epithelium turns columnar and nidus of gastric glands, circular muscular layer submucuosa noted by 18th week, longitudinal layer of muscle appeared at 20th week, parietal, zymogenand mucus neck cells observed by 24th week in fundus, and body oblique muscle was evident by 28th week and near adult pattern seen by 32nd week of gestation. Conclusion: From the available literature, very few studies have reported regarding histogenesis of human fetal stomach in India. The present study is one such to supplement the known data and knowledge regarding histogenesis of human fetal stomach and help in diagnosis and treatment of related congenital anomalies.

Symptomatic heterotopic pancreas of the jejunum: A case report

Introduction: Heterotopic pancreatic (HP) tissue defined as tissue that is found outside the anatomical location of the pancreas. It can occur anywhere in the gastrointestinal tract with the stomach and small bowel being the most common sites. The diagnosis of HP is considered difficult and usually discovered as an incidental finding in laparotomy. However, it can present as a case of intussusception or even perforation. Case Presentation: In this case, we report a 23-year-old male with a history of abdominal pain with vomiting that lasted for 7 days. Computed tomography (CT) scan was suggestive of intussusception. Laparotomy was done and a mass was found adherent to the jejunal wall. Partial resection of the jejunum was performed including the mass. The histopathological analysis confirmed it to be mixed exocrine and endocrine heterotopic pancreatic tissue. Conclusion: Heterotopic pancreatic tissue in the jejunum is rare. However, it should be considered in the differential diagnosis of jejunal masses.

Gastric Adenomyoma with Heterotopic Pancreatic Tissue.

Gastric Adenomyoma with Heterotopic Pancreatic Tissue.

GASTRIC AND PANCREATIC HETEROTOPIA PRESENTING AS PATHOLOGICAL INTUSSUSCEPTION IN AN ADULT FEMALE

Gastric and pancreatic heterotopias are rare entities. They have been identified throughout the entire length of the gastrointestinal tract and in other structures, including Meckel’s diverticulum and the Ampulla of Vater. However, very few cases of combined gastric and pancreatic heterotopias in ileum have been reported till date. Also, intussusceptions in adults are uncommon. Here we report a novel case of combined gastric and pancreatic heterotopia in ileum in a 32-year-old female. The patient presented with complaints of pain in abdomen and bleeding per rectum. On computed tomography, ileo-ileal intussusception was seen in the distal ileum. Exploratory laparotomy revealed an ileal polyp. The ileal segment with the polyp was resected and sent for histpathological examination. It was diagnosed as heterotopic gastric and pancreatic tissue in ileum. It highlights the importance of histopathological examination for definitive diagnosis of this rare clinical entity.

Meckel's Diverticulum Diagnosed by Balloon-Assisted Enteroscopy: A Multicenter Report from the Taiwan Association for the Study of Small Intestinal Diseases (TASSID).

Background and Aims Patients with Meckel's diverticulum (MD) are difficult to preoperatively diagnose because of its endoscopic inaccessibility. Balloon-assisted enteroscopy (BAE) allows endoscopic access to the entire small intestine. The aim of the current study was to investigate patients with MD diagnosed by BAE in Taiwan. Methods We conducted a retrospective, multicenter study of patients with MD who were diagnosed by BAE in Taiwan. The clinical characteristics, endoscopic features, histopathological findings, treatment methods, and outcomes were analyzed. Results A total of 55 patients with MD were enrolled (46 males and 9 females). The mean age at diagnosis was 34.1 years. Overt gastrointestinal bleeding (87.3%) was the primary indication for BAE, followed by abdominal pain (9.1%), suspected small bowel tumor (1.8%), and Crohn's disease follow-up (1.8%). The mean distance between the ileocecal valve and MD was 71.6 cm (regarding diagnostic yields: BAE—100%, capsule endoscopy—40%, Meckel's scan—35.7%, computed tomography—14.6%, small bowel series—12.5%, and angiography—11.1%; regarding endoscopic features of MD: a large ostium—89.1%, a small ostium—7.3%, and a polypoid mass—3.6%). Surgical treatment was performed in 76.4% patients, and conservative treatment was performed in 23.6% patients. The mean length of MD in 42 patients who underwent surgical resection was 5.2 cm (in 43 patients of MD with available histopathology: heterotopic gastric tissue, 42.4%, heterotopic gastric and pancreatic tissues, 7%; heterotopic pancreatic tissue, 4.7%; heterotopic colonic tissue, 2.3%; and a neuroendocrine tumor, 2.3%). Conclusions The current study showed BAE is a very useful modality for detecting MD compared with other conventional modalities.

A RARE CASE OF HETEROTOPIC PANCREATIC TISSUE CAUSING SMALL BOWEL OBSTRUCTION

A Rare case of heterotopic pancreatic tissue of ileum causing acute intestinal obstruction has been described with a brief review of literature. A 42 yr old male patient presented to the emergency department with features of acute intestinal obstruction. After evaluation patient was taken up for emergency laparotomy which revealed a band to be arising from ileum. Furthermore, there was a small growth in the ileal wall at the site of origin of the band. Hence resection of the growth was done and followed by ileoileal anastomosis. Later on, histopathological examination of the growth revealed it to be heterotopic pancreatic tissue. Heterotopic pancreatic tissue is often an incidental nding encountered in upper gastrointestinal tract during endoscopy and surgeries. But Symptomatic ectopic pancreas of ileum is relatively rare and they very rarely present with acute symptoms as in this case

S1573 A Rare Case of Ectopic Pancreas Spotted as a Small Nodularity in Distal Esophagus

Introduction: Heterotopic pancreatic tissue or ectopic pancreas is a congenital phenomenon in which there is presence of pancreas tissue outside of the main pancreas. The tissue is located at a separate site and is not connected to the main pancreas by means of ducts or vascular supply. We present a case of ectopic pancreatic tissue in the esophagus found on endoscopy. Case Description/Methods: A 71-year-old male with a history of gastroparesis and chronic bloating who presented to gastroenterology clinic for evaluation of flatulence. Physical exam was unremarkable and basic labs were normal. Despite a trial of low FODMAP diet and rifaximin, symptoms persisted. Hence upper endoscopy was performed and revealed salmon colored mucosal nodularity in distal esophagus which was biopsied. The gastric and duodenal mucosa appeared normal and biopsies were negative for celiac disease or Helicobacter pylori infection. The biopsy of the esophagus revealed focal pancreatic heterotopia with histological evidence of well-circumscribed small lobules of pancreatic tissue located in the submucosa underneath the esophageal squamous mucosa. There were basophilic basal granules and eosinophilic apical granules of the pancreatic acinar glands. The ectopic tissue did not contribute to any symptoms and was discovered as an incidental finding. Discussion: Ectopic pancreas can be present in various sites in the gastrointestinal tract though more frequently found in the upper tract at sites such as the stomach, duodenum and jejunum. However other sites such as the esophagus are an unusual site. It can be discovered incidentally or can have a symptomatic presentation. It can present with complications such as pancreatitis, bleeding, obstruction and may even be associated with malignant transformation in some cases. Ectopic pancreas in the esophagus is very rare and given its pre-malignant potential, gastroenterologists need to be aware and these lesions should be resected.Figure 1.: Figure A: Salmon colored mucosa noted in distal esophagus being examined under narrow band imaging. Figure B showing pancreatic heterotopia in distal esophagus on hematoxylin and eosin stain at 200X magnification. There are well-circumscribed small lobules of pancreatic tissue located in the submucosa underneath the esophageal squamous mucosa. Note the presence of basophilic basal granules and eosinophilic apical granule of the pancreatic acinar glands. A few dilated ducts are also noted.

Malignant Transformation of Heterotopic Pancreatic Tissue in a Patient with BRCA2 Mutation

Background: Malignant transformation of heterotopic pancreatic tissue is a rare entity with only several case reports published in the scientific literature. Adjuvant chemotherapy following oncological resection for lesions with nodal metastasis has not been well described and there are no guidelines available to guide the management of these patients. Case Presentation: We present a case of gastric heterotopic pancreatic carcinoma with nodal metastasis in a young patient with breast cancer gene (BRCA) 2 mutation. He had undergone a laparoscopic wedge resection for a gastric lesion initially thought to be a gastrointestinal stroma tumor. Given the involvement of the wedge resection margins, the patient underwent a distal gastrectomy with oncological lymph nodal clearance. One out of the 33 harvested lymph nodes harboured micrometastasis while the main gastrectomy specimen did not have any residual malignancy. Following the histological diagnosis, he received an adjuvant chemotherapy regime akin to that prescribed for locally advanced pancreatic adenocarcinoma with good response. This is, to our knowledge, also the first such case report in a patient with BRCA2 mutation. Conclusions: Pre-operative diagnostic confirmation is challenging and endoscopic procedures pose significant false negatives. Reports of nodal metastasis following oncological resection are limited and there are no guidelines regarding adjuvant therapies. We would recommend a chemotherapy regimen similar to that for primary locally advanced pancreatic carcinoma in patients found to have nodal metastasis.

Inverted Meckel's diverticulum associated with heterotopic pancreatic tissue causing intestinal obstruction: a case report

BackgroundMeckel’s diverticulum is the most frequent congenital anomaly of the gastrointestinal tract. It can invert or invaginate into the small intestine lumen. It is usually associated with heterotopic tissue elements.Case presentationWe present a case of inverted Meckel's diverticulum, clinically and radiologically diagnosed as intestinal obstruction due to intussusceptions. The diagnosis was suspected due to target sign shown on radiological examination. Pathologically, it was inverted Meckel's diverticulum obstructing the lumen in parallel plan mimicking the telescoping appearance, with heterotopic pancreatic tissue formed of exocrine and ductal components only.ConclusionsInverted Meckel’s diverticulum may present by vague symptoms and may simulate other causes of intestinal obstruction.

Esophageal Ulcer Due to Ectopic Pancreatic Tissue: A Case Report

Heterotopic pancreatic tissue, known as pancreatic rest, is a pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Common locations for this tissue include the stomach, duodenum, jejunum, Meckel diverticulum, and ileum. In this report, we present a case of a patient whose pancreatic rest was diagnosed primarily during the investigation of dysphagia with solid foods and it was located in the mid esophagus as an unusual location.

1761 Heterotopic Pancreatic, Sebaceous, and Gastric Tissue: Report of Case and Review of the Literature

INTRODUCTION: Heterotopic mucosa refers to the presence of normal tissue at a foreign site, and is thought to be either congenital from an error during organogenesis or metaplastic from an error during differentiation of pluripotent cells. We present a rare case of pancreatic and sebaceous gland heterotopia in the esophagus and gastric mucosal heterotopia in the rectum. To our knowledge, this is the first case with three types of heterotopia found in a single patient. CASE DESCRIPTION/METHODS: A 61-year-old man with GERD presented with periodic dysphagia to solids. He denied regurgitation, heartburn, melena, hematochezia, constipation, and diarrhea. Physical exam was unremarkable. Barium swallow showed a small hiatal hernia, and mild concentric narrowing at the GE junction. EGD showed a low grade Schatzki ring and diffuse beige 2-3 mm specks in middle third of esophagus. A colonoscopy was also scheduled for screening purposes and showed a 20 mm semi-sessile polyp in the rectum. Biopsies identified focal pancreatic and sebaceous gland heterotopia in the esophagus and gastric fundus heterotopia in the rectum. DISCUSSION: Heterotopic pancreatic, sebaceous, and gastric mucosa have been described along the entire GI tract. Our literature review identified 11 case reports of pancreatic heterotopia in the esophagus, 23 case reports of heterotopic sebaceous glands in the esophagus, and 73 case reports of gastric heterotopia in the rectum. However, no case reports found a single patient with all three types of heterotopia. In all three types, there was a male predominance, and ages ranged from birth to 6th decade of life. The origin of the heterotopic tissues is hypothesized to be either congenital vs metaplastic. As the combination of organ heterotopia described here includes components of mesoderm and endoderm, there was presumably incomplete cellular differentiation in weeks 2-3 of embryonic development. Patients can be asymptomatic or present with dysphagia, epigastric pain, or reflux with heterotopic pancreatic mucosa and sebaceous glands in the esophagus, and hematochezia with heterotopic gastric mucosa in the rectum. Treatment for the heterotopic tissues vary but surgical or endoscopic resection is typically pursued. Given that the tissue is often removed, it is unclear the malignant potential of the lesions and close follow up is necessary. Ultimately, presentations such as hematochezia and dysphagia may have rare etiologies and necessitates sufficient biopsies.

1306 Endoscopic Mucosal Resection of Pancreatic Rest Presenting as a Submucosal Nodule in the Gastric Antrum

INTRODUCTION: Pancreatic rest (PR) is defined as ectopic pancreatic tissue outside the normal pancreatic parenchyma, with a vascular and nerve supply separate from the pancreas itself and has a prevalence of 0.55-14%. It is believed to arise during rotation of the foregut, when fragments of the pancreas become separated from the main body and are deposited at ectopic sites. CASE DESCRIPTION/METHODS: An 82-year-old male with a history of GERD presented with episodes of epigastric abdominal pain of 2 month duration that did not improve despite PPI therapy. He denied any other symptoms such as bleeding, weight loss or change in bowel habits. Physical examination revealed a non-distended abdomen and mid-epigastric tenderness. An EGD performed for evaluation of GERD 3 years prior found an antral nodule. A repeat EGD was done this time for evaluation of the epigastric pain and showed a mobile submucosal nodule in the antrum measuring 7-8 mm, unchanged from before. EUS was performed for further evaluation and showed a hypoechoic gastric submucosal lesion, arising from the muscularis mucosa, 8 mm in size. No high-risk features were present. The area was resected using EMR and the defect was closed with clips. The EUS also showed a cystic dilation of the pancreatic duct in the pancreatic head measuring 5 mm, suspicious for main duct IPMN. Results from the EMR biopsy demonstrated heterotopic pancreatic tissue with focal low grade pancreatic intraepithelial neoplasia (PanIN), with clear margins and reactive gastropathy with focal intestinal metaplasia. There was resolution of the abdominal pain after the procedure. A repeat EGD/EUS will be done in 1 year. MRI will be performed in 6 months for surveillance of the pancreatic duct dilation. DISCUSSION: PR can be found virtually anywhere along the GI tract, but they are typically found in the stomach along the greater curvature and antrum. Although usually asymptomatic, the most reported symptom is mid abdominal pain. Complications of gastric ectopic pancreas include acute or chronic pancreatitis, necrosis, pseudocyst, gastric outlet obstruction and rarely carcinoma. PanIN is neoplastic epithelial proliferation that occurs in the small caliber pancreatic ducts; it is divided in 3 degrees based on architectural and nuclear atypia and has potential progression to invasive ductal adenocarcinoma. In our case, PanIN 1 was found on histology and the lesion was completely resected. PR should always be considered when evaluating a submucosal lesion of the GI tract.

Gastric outlet obstruction due to gastric duplication cysts with heterotopic pancreatic tissue treated by marsupialization

Abstract Gastric duplication cysts are rare congenital anomalies often treated with complete surgical excision, but this is not always possible. In such cases, resection and reconstruction have been advocated, but this may lead to significant morbidity. We present a unique case of a 3-year old girl who presented with complete gastric outlet obstruction due to multiple gastric duplication cysts with heterotopic pancreatic tissue treated with marsupialization and endoscopic surveillance as an alternative to gastric resection and reconstruction. This approach avoids morbidities from a more extensive procedure and in this case, alleviated the obstruction, averted sequelae secondary to heterotopic pancreatic tissue, and provides surveillance in the rare case of malignant degeneration. The child tolerated the procedure well and has been symptom free for the past year.

Intraductal papillary mucinous neoplasm developed on an ectopic gastric pancreas

In January 2014, a 69-year-old man with end-stage renal disease requiring dialysis was evaluated for kidney transplantation. During the work-up, abdominal ultrasound found an ill-defined intraabdominal cystic lesion. Abdominal magnetic resonance imaging revealed a 60 × 50 mm multiloculated cystic lesion developed over the lesser gastric curvature (Fig. 1). An endoscopic ultrasound (EUS) confirmed a subepithelial 60-mm a cystic gastric tumour. Fine needle aspiration was negative for malignancy. In order to rule out a primary gastric tumor, surgery was scheduled. A partial gastrectomy was performed with an uneventful postoperative course. Gross pathology found a 60-mm cystic tumor located into the gastric wall. Histology found heterotopic pancreatic tissue composed by ducts and acini (Fig. 2) into the gastric wall. Epithelial cells were mucin-secreting and columnar with extensive intestinal metaplasia and low degrees of atypia. Mucinous deposits were present over the lesser omentum. The diagnosis of intraductal papillary mucinous neoplasm (IPMN) with low grade dysplasia developed on heterotopic gastric pancreatic tissue was established. Six years later the patient was doing well under dialysis. The prevalence of heterotopic pancreatic tissues ranges from 0, 6 to15% and IPMN development has been rarely reported as a possible complication of a heterotopic pancreas [ [1] Patel N. Berzin T. Intraductal papillary mucinous neoplasm arising in a heterotopic pancreas: a case report. Am J Gastroenterol. 2010; 105: 2513-2514https://doi.org/10.1038/ajg.2010.298 Crossref Scopus (11) Google Scholar ]. Symptoms are unspecific and surgery should be advised based on the size and morphology of the lesion. Fig. 2Histological examination showing heterotopic pancreatic tissue into the gastric wall with acini and ducts. View Large Image Figure Viewer Download Hi-res image