Presence Of Heterotopic Gastric Mucosa Research Articles

Life-threatening gastrointestinal bleeding caused by jejunal heterotopic gastric mucosa in an adult dog: a rare case report

BackgroundHeterotopic gastric mucosa has been scarcely reported in the veterinary literature. Its presence can be asymptomatic or associated with various clinical signs ranging from apathy, vomiting, to abdominal pain. This report illustrates the presence of heterotopic gastric mucosa in the jejunum of an adult dog. It is the first to describe severe anemia, requiring acute blood transfusion, following intestinal hemorrhage caused by heterotopic gastric mucosa.Case presentationA twelve-year-old, intact male Maltese dog was presented with a history of apathy, vomiting and anemia. The dog was on a strict diet for recurrent diarrhea, food intolerance and skin allergy. Clinical examination revealed severe anemic mucous membranes and painful abdominal palpation. Blood examination confirmed severe regenerative anemia. Ultrasonography showed an intestinal neoplasm, gall bladder sludge and non-homogeneous liver parenchyma. Three-view thoracic radiographs failed to show any metastatic lesions or enlarged lymph nodes. After initial stabilization and blood transfusion, a midline exploratory laparotomy was performed. Three different masses were found in the jejunum. Resection and anastomosis of approximately 40 cm of jejunum was performed, followed by liver and lymph node biopsy and placement of an esophagostomy tube. Two days after surgery the dog started to clinically improve and was discharged from the hospital on the sixth day after surgery. Histopathology revealed the intestinal masses to be heterotopic gastric mucosa associated with intramural cystic distensions, multifocal ulceration and bleeding into the intestinal lumen. Two years after surgery, the dog did not have a recurrence of anemia or gastrointestinal signs.ConclusionsThis case demonstrates that heterotopic gastric mucosa can be considered one of the differential diagnoses in case of severe anemia due to gastrointestinal hemorrhage and suspected intestinal tumors. Although in most described cases in literature the finding seems to be incidental on necropsy, our report shows that heterotopic gastric mucosa can be the etiology of life-threatening signs. In addition, because no recurrent diarrhea episodes occurred after surgical resection of the ectopic tissue, it is likely that the heterotopic gastric mucosa was the cause of the food intolerance signs in this dog.

Prevalence of Helicobacter pylori infection rate in heterotopic gastric mucosa in histological analysis of duodenal specimens from patients with duodenal ulcer.

Heterotopic gastric mucosa in the duodenal bulb is a rare congenital disorder with varied clinical presentations. The mechanism of formation of a duodenal ulcer is failure of balance of the attack factor and the defense factor, which is the same as the mechanism of formation of a gastric ulcer. However, the true etiology of the duodenal ulcer remains unknown. Gastric mucosa can secrete gastric juice which injures itself, but the duodenal mucosa does not contain cells secreting a digestive enzyme. We assume that duodenal ulcers are caused by the presence of heterotopic gastric mucosa that can secrete gastric acid. This study was designed to assess the prevalence and associations of heterotopic gastric mucosa in duodenal ulcers. The present study included 137 patients who underwent biopsy or resection of duodenal ulcer. We detected gastric foveolar metaplasia due to inflammation from a heterotopic gastric mucosa using immunohistochemical staining. Heterotopic gastric mucosa consists of foveolar epithelium (MUC5AC-positive) and fundic gland (H⁺K⁺ ATPase-positive parietal cells, pepsinogen I-positive chief cells and MUC6-positive mucous neck cells), whereas gastric metaplasia is composed of foveolar epithelium without fundic glands. These specimens were stained with toluidine blue for detection of Helicobacter pylori infection. Among the 137 patients with duodenal ulcer, 76 cases (55%) had heterotopic gastric mucosa in the obtained specimens, and Helicobacter pylori was found in 45 cases (59%,45/76) among those with heterotopic gastric mucosa. Our results suggest that heterotopic gastric mucosa was strongly associated with concurrent duodenal ulcer.

Visual Diagnosis: 12-Year-Old Girl With Constipation And Rectal Bleeding

Rectal duplication cysts are rare, thought to be due to defects in embryologic development, and often associated with other structural abnormalities. Clues to the existence of a rectal cyst are mainly due to bowel compression and presence of ectopic gastric mucosa within the cyst, leading to rectal bleeding. The diagnosis of a rectal duplication cyst requires a high index of suspicion. Confirming the diagnosis can be difficult based on the location of the cyst. Efforts to confirm the diagnosis include digital rectal examination, computed tomography, magnetic resonance imaging, ultrasonography, and Meckel scan. Surgical resection is the treatment of choice, especially because of the cyst’s potential for malignant transformation. Because of the cyst’s proximal location to the nerves innervating the anal canal and sphincters, surgical resection can lead to fecal incontinence.

Gastric Heterotopia of the Rectum

Gastric Heterotopia of the Rectum

Segmental dilatation of the ileum in a healthy adolescent

Segmental intestinal dilatation is a rare entity presenting overwhelmingly in infants and young children with congenital malformations, anemia, or history of gastrointestinal pathology, characterized by a focally distended segment of bowel with abrupt transition points without an obstructing barrier. We present a 16-year-old girl with no significant medical history who presented with bowel obstruction clinically. Segmental dilatation of the ileum was evident on a CT scan and small bowel series. Following surgical resection, pathologic examination of the segment revealed the presence of heterotopic gastric mucosa. The girl's symptoms resolved after surgery. Awareness of the imaging presentation of this entity can inform the evaluation of older children with nonspecific symptoms mimicking bowel obstruction.

Management of alimentary tract duplication in children.

Duplication of the alimentary tract is rare but potentially dangerous. Five of 72 children with alimentary tract duplication treated between 1973 and 1992 died from postoperative complications; a further ten required more than one operation. Ileal duplications were the commonest, occurring in 16 patients (22 per cent). Thoracoabdominal duplications were the most complicated and responsible for much of the overall morbidity and mortality. Surgical complications were related to the size and location of the duplication, communication with the gastrointestinal tract or vertebral canal, presence of heterotopic gastric mucosa and involvement of mesenteric vessels. Complete excision of the duplication should be possible in most cases.

Clinical Quiz

Clinical Quiz

Meckel’s Diverticulitis: Diagnosis With Computed Tomography and Tc-99m Pertechnetate Scintigraphy

A diagnosis of Meckel's diverticulitis was reached preoperatively in a 7-year-old boy with severe left-sided abdominal pain and fever after technetium-99m pertechnetate scintigraphy indicated the presence of heterotopic gastric mucosa in a left lower quadrant mass that had been shown by computed tomography. The case illustrates the use of scintigraphy in confirming a suspected diagnosis of Meckel's diverticulitis and is an example of a Meckel's diverticulum in the lower left abdomen rather than the more common locations of the lower right and midabdomen.

Heterotopic gastric mucosa in a duplicate gallbladder

A 7-year-old girl presented with recurrent acute pancreatitis. Detailed investigations, including endoscopic retrograde cholangiography, suggested a poorly defined biliary tract abnormality. At laparotomy, this was discovered to be a duplicate gallbladder each with a separate cystic duct but contained within a single serosal envelope. Both gallbladders were removed, and histologic examination found the inferior organ to be lined by heterotopic fundic-type gastric mucosa. Despite the absence of any remaining structural biliary abnormality and no evidence of residual ectopic gastric mucosa, the patient experienced a few further episodes of self-limiting mild acute pancreatitis during the following 3 years. The presence of heterotopic gastric mucosa in a duplicate gallbladder has not been described previously.

Gastric pathology in Meckel's diverticulum. Review of cases resected between 1965 and 1995.

One hundred forty-nine case files of Meckel's diverticulum resected at our hospital between 1965 and 1995 were reviewed for the presence of heterotopic gastric mucosa. Of these, 140 cases were evaluated, and 25 demonstrated ectopic gastric mucosa. Six of these heterotopic tissue specimens contained no assessable surface mucosa; therefore only 19 were evaluated for gastric histopathologic changes. "Gastritis" was present in all reviewed cases, but the predominant pattern was that of reflux-type gastritis or gastropathy, which had not previously been documented at this location. This gastropathy was demonstrated in 58% of the cases and could also account for some of the symptoms that prompted removal of appendixes without inflammation. Chronic and chronic active gastritis were also demonstrated in a minority of cases, and those with moderate or severe activity were associated with peptic ulceration. No Helicobacter pylori-like organisms were detected with either modified Giemsa stain or hematoxylin-and-cosin (H&E) stain. Findings were inconclusive with regard to erosive gastritis related to nonsteroidal anti-inflammatory drugs in Meckel's diverticulum. That the proportion of ectopic gastric mucosa found in several studies (including this one) is about half that suggested in textbooks indicates a need for a better workup of resected Meckel's diverticulum and a search for all types of gastric disease if gastric heterotopia is present. Emphasis must be placed on identification of reflux-type chemical gastritis and gastropathy, which are often documented as normal mucosa.

A Case of Heterotopic Gastric Mucosa of the Terminal Ileum Presenting Multiple Diffuse Polyps

We report a rare case of inflammation of the terminal ileum presenting numerous diffuse pseudopolyps and erosions. The patient was a 41‐year‐old man with multiple polypoid lesions in the terminal ileum causing anemia and hypoalbuminemia, which were found incidentally during preoperative evaluation of an early gastric cancer. Ileocecal resection was performed, and histological examination revealed the presence of heterotopic gastric mucosa (HGM) with fundic‐type glands. Tuberculous colitis and non‐specific inflammatory bowel diseases, such as Crohn's disease and ulcerative colitis, were ruled out clinically and histologically, and no other primary lesions capable of causing gastric metaplasia, such as Meckel's diverticulum, were detected. We therefore concluded that the HGM in this patient was not a metaplastic response to inflammation, but rather of congenital inflammation‐inducing origin. To our knowledge, only 29 cases of HGM of the small intestine beyond the ligament of Treitz, excluding Meckel's diverticulum and other congenital anomalies of the bowel, have been reported in the literature. Furthermore, we have found no reference to cases similar to our present patient. (Dig Endosc 1996 ; 8 : 225‐230)

Duplications of the alimentary tract in infants and children

Duplications of the alimentary tract are rare congenital anomalies that could present a diagnostic as well as therapeutic challenge. Twenty-seven patients with duplications of the alimentary tract were treated at Childrens Hospital Los Angeles between 1961 and 1992. Ages ranged from a few days to 5 years (67% younger than 1 year). The most common symptoms were nausea and vomiting, and the most common sign was a palpable abdominal mass. Three patients presented with gastric duplication, which was excised. The majority of the duplications were in the jejunum and ileum. All patients except one had primary resection of the duplication. One patient with a 45-cm tubular jejunal duplication was treated with mucosal stripping of the duplication. Five patients had cecal duplication, three patients presented with melena because of ectopic gastric tissue in the duplication, and two presented with intestinal obstruction. One of the latter patients presented with intussusception with cecal duplication as the leading point. Three patients with colonic duplication presented with abdominal pain and vomiting leading to excision of the duplication. Of the five patients with rectal duplication, three presented with chronic constipation. The other two patients presented elsewhere with perianal swelling, which eventually was drained because of a mistaken diagnosis of perianal abscess. Subsequently, these two patients came to us with persistent perineal fistula. In all our patients, rectal duplications were removed through a sacroperineal incision. The only patient in this series who died was a 6-week-old boy with gastric duplication; his death was attributed to an associated severe cardiac lesion. In patients with gastrointestinal symptoms, duplications should be considered in the differential diagnosis. If the intestinal duplication is short, the lesion can be removed with the adjacent normal bowel. For long duplications, mucosal stripping of the duplication is performed to preserve the adjacent bowel. The common blood supply shared by the duplication and the bowel must be carefully protected to avoid sacrifice of the bowel. The presence of heterotopic gastric mucosa in the duplication negates internal drainage of the lesion into the adjacent bowel.

Heterotopic gastric mucosa and pancreatic tissue in the skin of the abdominal wall

A lesion in the upper abdominal wall of a 10-year-old boy had been excised twice at the age of 3 years at another hospital but the lesion recurred shortly thereafter. We completely excised this lesion and histological examination showed the presence of heterotopic gastric mucosa and pancreatic tissue in the skin of the abdominal wall.

Duplications of the Alimentary Tract

Duplications of the alimentary tract are unusual congenital anomalies that frequently present a diagnostic as well as therapeutic challenge to the surgeon. Because these lesions occur so infrequently, they are often not suspected until encountered intraoperatively. Due to the complicated anatomy and common blood supply shared between the duplication and associated native bowel, appropriate management requires a familiarity with the anatomy and clinical characteristics of this entity. To better define the range of patient characteristics, clinical presentation, and preferred therapy, 20 enteric duplications were reviewed in 17 patients treated at the Children's Hospital Medical Center from 1956 to 1986. Ages of patients ranged from 1 day to 11 years; 60% were less than 2 years of age at initial presentation. Seven duplications in six patients involved alimentary tract structures of foregut derivation (esophagus, stomach, and Parts I and II of duodenum), with a predominance of girls (4 of 6). Most of these patients (67%) presented with moderate to severe acute respiratory distress and a mass present on chest radiograph. In 67% of the patients, the correct diagnosis was established before operation. None required emergency operative intervention. By contrast, 13 duplications in 11 patients were of midgut or hindgut derivation (Parts III and IV of the duodenum, jejunum, ileum, and colon). In this group of patients, 62% of the duplications involved the cecum, 23% involved the ileum, and 16%, the jejunum. Seventy-eight per cent of the patients were boys. The most common symptoms were nausea and vomiting, and the most common sign was a palpable abdominal mass. Emergency operative intervention was required of eight of 11 patients with duplications involving the small bowel and colon. Three patients presented with an intussusception, four with signs and symptoms consistent with acute appendicitis, one with a small bowel obstruction, and two with gastrointestinal hemorrhage due to the presence of ectopic gastric mucosa within the duplication. It was found that two important points must be considered in regard to the management of enteric duplications: (1) the common blood supply shared between the duplication and native bowel must be carefully protected to avoid undue sacrifice of normal bowel, and (2) the presence of heterotopic gastric mucosa in 35% of patients negates internal drainage.(ABSTRACT TRUNCATED AT 400 WORDS)

Heterotopic Gastric Mucosa in a Perforated Appendix

A fifty-five year old male with an appendicular abscess had 100 ml of pus drained from the right lower quadrant. Two months later, an interval appendectomy was performed. The macroscopically normal appendix had a portion of fibroadipose mesoappendix attached. Microscopic evaluation using routine stains showed redundance and diverticular extrusion as well as foci of ectopic gastric glands. Immunohistological studies for detection of gastrin immunoreactivity revealed gastrin containing cells in foci of ectopicgastric glands. This represents the first report in which gastrin was demonstrated in an appendix, confirming the presence of heterotopic gastric mucosa.