Pancreatic Rest Research Articles

Heteropic Pancreatic Rest in Gall Bladder: Is It Really Worrisome?

Abstract Heterotopia of pancreas is defined as an abnormal location of pancreatic tissue devoid of vascular and anatomical connections from main pancreas. The stomach is the most common site of such heterotopia, although the lesion can be encountered throughout the entire gastrointestinal tract. Involvement of gallbladder is extremely rare with few cases reported so far in the literature. We described a similar finding in a 28-year-old female patient, who presented with chronic abdominal pain.

Spectrum of endoscopic gastric subepithelial lesions encountered on EUS-FNA: A single center experience.

Endoscopic ultrasound guided fine needle aspiration (EUS-FNA) is a minimally invasive and reliable non-surgical technique for the diagnosis of gastrointestinal lesions. The present study aimed to evaluate the spectrum of lesions encountered in the gastric subepithelium on EUS-FNA at a tertiary care center. Archival data of all patients undergoing EUS-FNA for gastric submucosal lesions over a period of 5 years was retrieved. Patient demographics, clinical presentation, and EUS findings were recorded along with the FNA results. A total of 78 EUS-FNA samples were analyzed. Material was adequate in 62 cases (79.48%) and inadequate in 16 cases (12.82%) patients due to scant cellularity. Of the adequate samples, 34 (43.5%) were reported as neoplastic while 20 (25.64%) were non-neoplastic, and 8 (10.25%) were reported as suspicious of a neoplasm. In the neoplastic category, the predominant diagnosis was of spindle cell neoplasm comprising gastrointestinal stromal tumor (13), benign neural tumor (03), leiomyoma (02), and spindle cell tumors (03). The latter could not be categorized further due to a lack of IHC material. The next common diagnosis was adenocarcinoma (06) followed by neuroendocrine tumor (02) and poorly differentiated carcinoma (01). The non-neoplastic lesions included non-specific pathology (15), inflammatory lesions (08), and one case each of tuberculosis, pancreatic rest, and Brunner gland hamartoma. Cell blocks for ancillary testing were available in 54 cases (65.23%) and follow-up was available in 42 cases (53.84%). EUS-FNA is a good modality for the diagnosis of gastric submucosal lesions with a high diagnostic yield.

Enhancing gastrointestinal submucosal tumor recognition in endoscopic ultrasonography: A novel multi-attribute guided contextual attention network

Endoscopic ultrasonography (EUS) is a valuable imaging modality for diagnosing gastrointestinal submucosal tumors (SMTs). However, inherent content variations in EUS images due to gastrointestinal tract mobility and handheld ultrasound instability challenge the saliency of SMTs’ visual features. The presence of fine-grained inter-class and large intra-class differences further complicates EUS-based diagnosis. To address these issues, this paper presents a novel Multi-Attribute Guided Contextual Attention Network (MAG-CA-Net) for interpretable SMT recognition in EUS. Inspired by endoscopists’ clinical diagnosis expertise, our framework initially localizes abnormal areas based on echo attributes and subsequently determines tumor categories using contextual semantics. Experimental results demonstrate the effectiveness of MAG-CA-Net, exhibiting improved recognition recall and precision rates for gastrointestinal stromal tumor, leiomyoma, and pancreatic rest. Specifically, the MAG network facilitates abnormal area localization, while the CA mechanism guides the model to focus on the most discriminative tumor-context-associated regions. The proposed method achieved an average classification accuracy of 93.16%, an average precision of 93.17%, a weighted recall of 93.16%, and an average F1-score of 93.15 % for the three disease categories. The proposed approach provides crucial guidelines for data collection standards and model development in the clinical diagnosis process of SMTs under EUS. Its interpretability analysis enhances the credibility of clinical physicians towards assisted diagnostic methods based on deep learning. The source code will be publicly available at https://gitee.com/HangbinZheng/mag-ca-net.

Nasogastric versus nasojejunal tube feeding for severe acute pancreatitis: A systematic review of randomized controlled trials

Early enteral nutrition through a feeding tube is essential for the management of severe acute pancreatitis (SAP). Nasojejunal tube nutrition has been preferred on the assumption that it provided pancreatic rest in comparison to the nasogastric tube. However, nasojejunal tube placement is complex, may delay feeding initiation and can increase hospital costs. Our aim was to compare the efficacy and safety of enteral feeding with a nasogastric tube versus nasojejunal tube in patients with SAP. We searched four databases (PubMed, Web of Science, Scopus, and Embase) until December 1, 2022. We included randomized controlled trials (RCTs) comparing enteral feeding by nasogastric and nasojejunal tubes in patients with SAP. Primary outcome was all-cause mortality. Secondary outcomes were organ failure, infection, complications, surgical intervention, duration of tube feeding and length of hospital stay. Risk of bias assessment was completed independently by two investigators using the Cochrane RoB 2.0 tool. We performed random effects model meta-analyses using the inverse variance method. Effect measures were reported as relative risks (RR) and their 95% CIs for dichotomous outcomes and mean differences (MD) and their 95% CIs for continuous outcomes. We included four RCTs involving 192 patients with SAP. The mean ages ranged between 36 and 62 years old. There was no significant difference in all-cause mortality between the nasogastric and nasojejunal feeding arms (18/98 vs. 23/93; RR 1.34, 95%CI 0.77–2.30; p=0.30). There were no significant differences in all secondary outcomes between feeding arms. There were three RCTs with some concerns of bias, in the randomization process. In conclusion, in patients with SAP, enteral feeding delivered by nasogastric tube was as efficacious and safe as nasojejunal tube. Further randomized controlled trials with more participants and better design are needed to confirm these findings.

Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence.

The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.

REST is a major negative regulator of endocrine differentiation during pancreas organogenesis.

Multiple transcription factors have been shown to promote pancreatic β-cell differentiation, yet much less is known about negative regulators. Earlier epigenomic studies suggested that the transcriptional repressor REST could be a suppressor of endocrinogenesis in the embryonic pancreas. However, pancreatic Rest knockout mice failed to show abnormal numbers of endocrine cells, suggesting that REST is not a major regulator of endocrine differentiation. Using a different conditional allele that enables profound REST inactivation, we observed a marked increase in pancreatic endocrine cell formation. REST inhibition also promoted endocrinogenesis in zebrafish and mouse early postnatal ducts and induced β-cell-specific genes in human adult duct-derived organoids. We also defined genomic sites that are bound and repressed by REST in the embryonic pancreas. Our findings show that REST-dependent inhibition ensures a balanced production of endocrine cells from embryonic pancreatic progenitors.

Acute Pancreatitis in Children.

Acute pancreatitis has become a common general pediatric condition with an increasing incidence over the past 2 decades. It presents with nonspecific complaints of abdominal pain, vomiting, and nausea. Therefore, it is crucial to have it on the differential diagnosis, as it requires prompt treatment and has the potential to become life-threatening. Although pancreatic rest, antiemetics, analgesia, and hydration remain the mainstay of treatment, a new perspective on fluid management, early enteral nutrition, and opioid use has evolved. This review identifies gaps in management awareness and provides understanding on long-term implications of acute and recurrent pancreatitis. This article also reviews the epidemiology, diagnostic criteria, imaging and procedural modalities, common causes, management, and complications of acute pancreatitis and is geared toward the general pediatric hospitalist. [Pediatr Ann. 2021;50(8):e330-e335.].

Pancreatic rest in a young woman: a rare cause of dyspepsia

Pancreatic rest in a young woman: a rare cause of dyspepsia

Ectopic pancreatic rest in the stomach

The journal is the official publication of the College of Surgeons of Sri Lanka. Its mission is to reach the highest standard of scientific surgical practice by dissemination of high quality scientific information and to foster and promote the growth of scientific surgery in Sri Lanka and in the region. The Sri Lanka Journal of Surgery publishes peer-reviewed leading articles, review articles, scientific articles, perspectives and case reports in the field of surgery and broadly related surgical sciences The journal adheres to the publication ethics as portrayed by the Committee on Publication Ethics (COPE) and is a member of this organisation. It is listed as an ICMJE journal which follow its recommendations (ICMJE recommendations) on Conduct, Reporting, Editing and Publication of Scholarly Work in Medical Journals.

Nutrición en pancreatitis aguda: nuevos conceptos para un viejo problema

El manejo de la nutrición en pancreatitis aguda ha sido cuestión de debate. Durante muchos años el concepto de reposo pancreático fue generalizado y aceptado en el manejo de la pancreatitis aguda; actualmente se conoce que la nutrición temprana permite mantener la integridad de la barrera intestinal, que previene la aparición de complicaciones infeccionas y se asocia con una menor estancia hospitalaria, menos complicaciones y un mejor pronóstico. En esta revisión se discuten las principales ventajas de la nutrición temprana en pancreatitis aguda, la seguridad de la misma y la vía de administración.

Evaluation and management of a pancreatic rest noted during pre-bariatric surgery screening endoscopy.

Pancreatic rest (PR) is an ectopic pancreatic lesion that is usually found incidentally on endoscopy or surgery. While most lesions do not have clinical significance, some patients are symptomatic and rarely, PR can predispose to malignancy. With the growing popularity of bariatric surgery, it has been unclear how to manage PR found on screening endoscopies, prior to bariatric surgery. Through review of the current literature, we propose an algorithm for clinicians to evaluate and manage PR found on screening endoscopies prior to bariatric surgery. We performed a literature search in PubMed pertaining to PR, clinical characteristics, risk of malignant transformation, endoscopic characteristics, histological descriptions, and resection techniques. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found 33 published articles from 2001 to 2019, including case reports, case series, retrospective cohorts, and a review paper. PR is commonly found incidentally in the gastric antrum. Larger lesions have a higher risk of being symptomatic or predisposing to malignant transformation. Endoscopic ultrasound (EUS) can assist in the diagnosis of PR and guide resection technique. Certain histological characteristics, such as Heinrich class, grading of neoplasia, and genetic alterations, can determine malignancy risk of PR. Resection technique, either endoscopically or surgically, should be based on lesion size, depth of wall invasion, and the endoscopists' level of skill in endoscopic resection. Proper evaluation and treatment of PR should be considered because of the risk for symptoms and malignant transformation. Symptomatic lesions and those at risk for malignant transformation should be considered for resection. EUS can guide the diagnosis and type of resection, either endoscopically through EMR or ESD or surgically through sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB).

Su1315 DIFFERENCES IN THE DIAGNOSTIC YIELD BETWEEN EUS GUIDED FINE NEEDLE ASPIRATION (FNA) AND CORE BIOPSY (FNB) NEEDLES IN THE EVALUATION OF SUBEPITHELIAL LESIONS IN THE UPPER GASTROINTESTINAL TRACT

Establishing the histological diagnosis of subepithelial lesions (SEL) can be challenging. Even with rapid on-site cytology (ROSE), the diagnostic yield of EUS-FNA is low (40-65%) as core tissue is often required for ancillary studies such as immunohistochemistry (IHC) stain. Newer EUS-FNB needles are designed to obtain core tissue. This study aimed to compare the diagnostic yield of conventional FNA needles with the newer FNB needles in EUS guided tissue acquisition of SEL in the upper gastrointestinal tract. A prospectively collected database on all patients who were referred for EUS guided tissue acquisition of SEL in the upper GIT over 10 years was retrospectively reviewed. All EUS FNA/FNB procedures were performed without ROSE, and all material from the needles were placed into formalin for direct histological examination. The conventional group included specimens obtained from the 22G and 25G FNA needles and 25G reverse bevel needle. The FNB group included specimens from the 20G or 22G reverse bevel needle. The final diagnosis was based on either surgical specimens or from repeat FNA or FNB specimens with at least 6 months of clinical follow up. Specimens from 178 SEL taken from 166 patients, of which 100 were by FNB needles and 78 by FNA needles. There were no differences in demographics, lesion size and location of the lesion along the upper GIT tract between the group. The needle caliber used in each group as well as the diagnoses are summarized in Table 1. The diagnostic accuracy (86/100 vs 45/78; P<0.001) and ability of perform IHC (70/100 vs. 28/78; P<0.001) were substantially higher with FNB than FNA needles. The number of passes were similar in both groups (FNB=2.2± 0.8 vs 2.3±0.9; P=0.61). Of the non-diagnostic cases (n=47), 29 (61%) were smaller than 15mm, and were suspected to be lipomas (n=22), leiomyomas (n-18), pancreatic rest (n=5) or duplication cysts (n=2) based on EUS evaluation. No patients reported or were re-admitted due to pain, bleeding or perforation. Even with a similar number of needle passes and no ROSE, FNB needles achieved a higher diagnostic accuracy than FNA needles for EUS guided tissue acquisition of SEL, suggesting that FNB is the needle of choice for SEL.

Nutrition management in acute pancreatitis: Clinical practice consideration.

Acute pancreatitis (AP) is a common gastrointestinal disease and the leading cause of hospital admission and healthcare burden among gastrointestinal disorders in many countries. Patients can present with varying degrees of inflammation and disease severity, ranging from self-limiting mild AP to devastating and fatal severe AP. Many factors contribute to malnutrition in AP, especially abnormal metabolism and catabolism related to inflammation. The concept of "pancreatic rest" is not evidence-based. There is however, emerging evidence that supports the use of oral or enteral nutrition to improve nutrition status and to reduce local and systemic inflammation, complications, and death. In mild disease, patients are generally able to initiate solid oral diet and do not require specialized nutrition care such as enteral or parenteral nutrition. In contrast, nutrition interventions are imperative in moderately severe and severe AP. The current article aims to review the latest evidence and suggest practical nutrition interventions in patients with AP, including nutrition requirements, routes of nutrition treatment, types of formula, and the role of nutritional supplements, such as glutamine, probiotics, omega-3 fatty acids, and antioxidants.

Digestive findings that do not require endoscopic surveillance - Reducing the burden of care: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement.

With the aim of reducing the overall burden of care, ESGE recommends against surveillance of a series of conditions. Namely: ESGE RECOMMENDS: against surveillance of individuals with the following: an inlet esophageal patch; Los Angeles (LA) grade A or B erosive esophagitis; or < 1 cm columnar-lined esophagus. ESGE RECOMMENDS: against surveillance of those with intestinal metaplasia limited to the antrum unless additional risk factors are present, such as persistent Helicobacter pylori infection, incomplete metaplasia, or a family history of gastric cancer; or for fundic gland polyps in the absence of suspicious endoscopic features or hereditary syndromes. ESGE RECOMMENDS: against surveillance of gastrointestinal leiomyomas, lipomas, and antral pancreatic rests, provided that these lesions have typical ultrasonographic features. ESGE RECOMMENDS: against routine endoscopic surveillance in duodenal peptic ulcer, unless symptoms persist despite adequate therapy. ESGE SUGGESTS: against surveillance of confirmed pancreatic serous cystic neoplasms. ESGE RECOMMENDS: against endoscopic surveillance for patients with hyperplastic polyps in the rectosigmoid, with 1 - 4 adenomas < 10 mm with low-grade dysplasia, or with a serrated polyp < 10 mm without dysplasia. ESGE RECOMMENDS: against surveillance of gastrointestinal conditions in individuals over 80 years old who have less than 10 years of life expectancy and poor general health status.

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.

2674 Laying a Gastric Wall Abscess to Rest

INTRODUCTION: Gastric wall abscess (GWA) or localized suppurative gastritis is a purulent inflammatory process of the submucosa of the stomach associated with high mortality rates. GWA can be a rare complication of subepithelial lesions (SEL), such as ectopic pancreas (pancreatic rest), GIST, and leiomyosarcoma. Our report is the fourth demonstrated case of pancreatic rest associated GWA and the first in an extensive literature search with successful treatment without adjunctive surgical resection. CASE DESCRIPTION/METHODS: 38-year-old healthy female presented to our Gastroenterology clinic for persistent abdominal pain with nausea and vomiting after being evaluated 3 days ago at an outside hospital (OSH) (Table 1). She was diagnosed with gastritis and sent home on omeprazole. At our institution, she described her pain as sharp, constant, non-radiating and diffuse, but worst in the epigastrium postprandially. Social history was remarkable for 1-2 drinks per day and recent travel to Peru 3-4 weeks prior. As she appeared acutely ill, the patient was referred to ED, with initial work up remarkable for blood pressure of 93/54 and WBC of 13.5. EGD revealed a large submucosal gastric mass in the distal gastric antrum with central umbilication and expressible white purulent material (Figure 1). She was started on pip/tazo and ID was consulted. Micro was largely negative; however, culture of purulent material was unable to be processed. Pathology showed active gastritis, focal ulceration, and necro-inflammatory tissue without evidence of malignancy. Cytology revealed purulent exudate associated with bacterial colonies consistent with abscess. The patient clinically improved and was discharged home on Augmentin. In outpatient follow up, patient reported continued improvement. Follow up EGD revealed resolution of abscess, however pancreatic rest was seen in the gastric antrum (Figure 2). DISCUSSION: GWA is a rare and highly morbid condition commonly located in the antrum or pylorus. Exact pathogenesis may be due to direct bacterial seeding or hematogenous spread. Strep species are the most commonly isolated bacteria. GWA is rarely also associated with a SEL, in our case being a pancreatic rest, or ectopic pancreatic tissue. Treatment for SEL associated GWA has traditionally been surgical removal with either partial gastrectomy or wedge resection. Our case report demonstrates the safety and efficacy of drainage and medical management alone.

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.

Heterotrophic Pancreatic Rest Mimicking Tumor in Stomach: A case Report and Literature Review

Pancreatic heterotopia is an entity defined by extra pancreatic tissue without any anatomic or vascular continuity with the pancreas.

Image Case : Pancreatic Rest

18 years old female patient presented by epigastric pain and dyspepsia.Upper gastrointestinal endoscopy revealed umplicated small antral mass(pancreatic rest). Pancreatic rests are benign congenital anomalies defined as pancreatic tissue that lacks anatomic or vascular continuity with the pancreas itself . Also referred to as pancreatic heterotopia, heterotopic pancreas, ectopic pancreas, aberrant pancreas, and accessory pancreas. Although they can be located in many sites throughout the body, they are most commonly found in the upper gastrointestinal tract, with the gastric antrum being the most common site. The differential diagnosis of gastric antral subepithelial lesions includes benign entities such as pancreatic rests, lipomas, inflammatory polyps, hyperplastic mucosa, Leiomyoma and cysts as well as entities with malignant potential such as carcinoid tumors and gastrointestinal stromal tumors. Mucosal biopsies can exclude epithelial tumors, and EUS can help exclude other lesions (such as cysts, lipomas, stromal tumors, or extrinsic lesions). The treatment of symptomatic pancreatic rest is:Endoscopic band ligation snare polypectomy(EBLSP) or Surgery. EUS should be performed prior to endoscopic mucosal resection to ensure safety of resection by making sure the lesion is superficial, not vascular, and does not involve the muscularis propria.

A Vanishing Heterogeneous Mass Arising From the Antrum: Ectopic Pancreatitis Masquerading as Malignancy

Ectopic pancreas, also known as pancreatic rest is defined as pancreatic tissue without vascular or anatomic communication with the main body of the pancreas. This case highlights the importance of a broad differential to abdominal pain and the work-up of a unique case of pancreatic rest masquerading as neoplasm and infection. A 32-year-old woman with a history only significant for B12 deficiency and travel to Singapore, Taiwan and Cuba who presented with gradually worsening epigastric discomfort, with transition to abdominal pain, nausea and vomiting. On admission, the patient was clinically stable, with vital signs of normal limits. Physical examination revealed tenderness to palpation and guarding in the right upper quadrant and epigastrum without peritoneal signs. Serum laboratory tests were significant for a leukocytosis (17.7x103 white cells per cubic millimeter) with a predominance of neutrophils (80%). Computerized tomography showed a 9.5cm complex, partially cystic mass at the gastroduodenal junction with thickened gastric wall and distorted 1st and 2nd portion of the duodenum. Endoscopic ultrasound with fine needle aspiration demonstrated a heterogeneous mass of 5 cm arising from the antrum, with normal appearance of the pancreas, and growth of mixed gram-positive flora. Duodenal perforation was suspected, she was started on antibiotics and offered surgical exploration, which she declined and presented to another hospital for a second opinion. Repeat CT showed improvement in the size of the mass with a 1cm cystic focus in the gastric antrum ([email protected]@@gure A). Post discharge, upper endoscopy, showed no fluid collection, mass or abscess where that had previously been a mass. However, a 12x9 mm heterogeneous lesion was seen arising from the second layer of the gastric wall in the antrum, consistent with pancreatic rest ([email protected]@@gure B). The patient was diagnosed with pancreatitis and a peri-pancreatic abscess occurring in the ectopic pancreatic tissue. The patient was discharged home with no further intervention. Infection or inflammation of ectopic tissues is an easily missed diagnosis that can lead to unnecessary malignancy work-up and surgery, as nearly occurred in this patient. Diagnosis is further made difficult because fine needle aspiration is superficial and results routinely show normal gastric biopsy, as was seen in our patient. Ectopic pancreas is an important consideration to prevent unnecessary work up and shorter hospitalization time for patients.1288_A.tif Figure 1: Computerized tomography of the abdomen showing improvement in the size of the original mass with a peripherally enhancing 2.1 cm fluid collection adjacent to the gastric antrum with mural thickening, as well as a 1 cm cystic focus in the gastric antrum.1288_B.tif Figure 2: Endoscopy with evidence of 12x9 mm heterogeneous round lesion arising from the second layer of the gastric wall in the antrum, consistent with pancreatic rest. The remainder of the pancreatic parenchyma was well seen without evidence of calcification, mass, chronic pancreatitis or any cystic lesion. Complete endoscopy showed no fluid collection, mass or abscess where there had previously been a large mass.