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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 51  |  Issue : 4  |  Page : 167-170

Heterotopic subserosal pancreatic tissue in jejunum


Department of General Surgery, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India

Date of Submission25-May-2017
Date of Decision10-Aug-2017
Date of Acceptance21-Dec-2017
Date of Web Publication22-Aug-2018

Correspondence Address:
Prof. Manish Swarnkar
M4/10, Jawaharlal Nehru Medical College Campus, Sawangi (M), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_88_17

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  Abstract 

Heterotopic pancreas (HP) is typically an asymptomatic malformation that can present anywhere along the gastrointestinal tract. It is frequently detected incidentally on surgery for other diseases or autopsy. We encountered an incidentally detected subserosal nodule in proximal jejunum during exploratory laparotomy for other cause which was resected and on histopathology confirmed to be HP. Histologically, most of the tumors are located in the submucosa, rarely in the muscularis propria, and only seldom in the subserosal. This case is of great interest because of the subserosal location of the tumor.

Keywords: Computed tomography, heterotopic pancreas, jejunum, subserosal


How to cite this article:
Swarnkar M, Pandey P. Heterotopic subserosal pancreatic tissue in jejunum. Formos J Surg 2018;51:167-70

How to cite this URL:
Swarnkar M, Pandey P. Heterotopic subserosal pancreatic tissue in jejunum. Formos J Surg [serial online] 2018 [cited 2020 Sep 26];51:167-70. Available from: http://www.e-fjs.org/text.asp?2018/51/4/167/239556


  Introduction Top


Heterotopic pancreas (HP) is a congenital anomaly defined as pancreatic tissue that has no contact with the orthotopic pancreas and has its own duct system and vascular supply.[1] The term was first used by de Castro et al.[2] and its reported point prevalence ranged from 0.55% to 13.7%.[3] This anomaly has been reported to occur in several locations in the abdomen and mediastinum, mostly in the stomach, duodenum, and the upper part of the jejunum.[3] The lesions are usually small, ranging from a few millimeters to a few centimeters in diameter, asymptomatic, and incidentally discovered at laparotomy or autopsy.[4] Histologically, most of the tumors are situated in the submucosa, rarely in the muscularis propria, and only seldom (around 13.5%) in the subserosa.[5] The present report describes a rare case where the ectopic pancreatic tissue was located in the jejunum as a subserosal tumor.


  Case Report Top


A 65-year-old female presented in our hospital with pain in the abdomen, fever off and on, and vomiting after eating for 10 days. On physical examination, tenderness in epigastrium was the only finding. Laboratory examinations showed elevated WBC count 14.6 × 10≥/μL (reference range: 5–10 × 10≥/μL) and raised erythrocyte sedimentation rate equal to 42 mm/h (reference range: 20–30 mm/h)]. Serum amylase (116 U/L), serum lipase (138 U/L), and serum calcium (10.1 mg/dL) were within normal limits. On contrast-enhanced computed tomography, there was collection in mesentery and thickening of small bowel wall with extraluminal gas. The patient was taken for exploratory laparotomy, and there was mesenteric abscess present at root of the mesentery. Abscess was drained and adhesiolysis was done. On further exploration, incidentally, at the proximal jejunum, a 4 cm × 3 cm yellow-white nodule was recognized [Figure 1]. The nodule was located in the subserosa of the jejunum and was excised. The site of incision was repaired with sutures. The patient remained asymptomatic without complications postoperatively, with normal laboratory values and was discharged on the tenth postoperative day.
Figure 1: Intraoperative image showed subserosal tumor in proximal jejunum

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The pathology report of the nodule confirmed the presence of ectopic pancreatic tissue with glandular acini, ducts, and absence of islet cells of Langerhans within the muscularis propria and subserosa of jejunum [Figure 2] and [Figure 3].
Figure 2: Histology shows pancreatic acinar tissue in the jejunum wall (H and E, ×40)

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Figure 3: Histology shows the details of benign pancreatic exocrine acinar lobule with ducts within muscularis mucosa (typical of pancreatic heterotopia) (H and E, ×25)

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  Discussion Top


HP is defined as pancreatic tissue that lacks an anatomic or vascular communication with the normal body of the pancreas.[6] Although HP can occur throughout the entire gastrointestinal tract, it is most commonly found in the stomach (25%–38%), duodenum (17%–36%), and jejunum (15%–21%).[7]

HP can be pathologically subdivided into four subtypes. Type 1 heterotopia consists of typical pancreatic tissue. The remaining subtypes consist of specific components of normal pancreatic tissue such as pancreatic ducts only (type II), acinar tissue only (type III), or islet cells only (type IV).[8] The development of heterotopic pancreatic tissue is unclear. The two predominant theories of origin of HP involve misplacement of pancreatic tissue during development versus tissue metaplasia. Embryologically, the pancreas develops from the invaginations of endodermal tissue in the primitive duodenum. The ventral aspect forms the head of the pancreas and the dorsal aspect forms the body and tail. The misplacement theory proposes that, during rotation of the foregut, several elements of the primitive pancreas become separated and eventually form mature pancreatic tissue along the length of the gastrointestinal tract.[6] The metaplasia theory states that pancreatic heterotopia arises from the areas of pancreatic metaplasia of the endoderm which migrate to the submucosa during embryogenesis.[9] These lesions are usually clinically silent, when present; symptoms vary depending on the anatomical location and size of the lesion. Abdominal pain, nausea, vomiting, and gastrointestinal bleeding are the most commonly reported symptoms and are most likely to be seen with lesions greater than 1.5 cm in diameter.[6]

Gastric lesions are the most likely to be symptomatic, presenting with either epigastric pain or symptoms of gastric outlet obstruction due to a prepyloric mass.[10] Rarely, jejunal lesions may result in intestinal obstruction or intussusception.[11]

HP also may present with symptoms related to complications similar to those normally associated with the pancreas. Cases of pancreatitis due to gastric lesions have been reported.[12] The incidence of malignant transformation of ectopic pancreas has been reported to range from 0.7% to 1.8%.[13] Criteria have been proposed for the diagnosis of carcinoma from an ectopic pancreas as follows: (1) The tumor must be located within or near the ectopic pancreas tissue, (2) transition between pancreatic tissue and carcinoma must be observed, and (3) the nonneoplastic pancreatic tissue must comprise fully developed acini and ducts.[13]

HP has several characteristic radiographic and endoscopic features that aid in its identification. Gastric HP classically presents as a rounded filling defect with a central indentation on barium studies or as a broad based, umbilicated, and submucosal lesion on endoscopy.[14] This central umbilication results from a subjacent pancreatic duct. However, these features are not always present, leading to a difficulty in diagnosis.

Various imaging tests can be used to identify HP in the gastrointestinal tract. It is important to stress that these tests are almost always performed to evaluate more common causes of abdominal symptoms, and the finding of HP is usually incidental. Computed tomographic findings are usually nonspecific although heterotopic pancreatic tissue can enhance to the same degree as normal pancreas with intravenous contrast. Newer technologies such as capsule endoscopy and single bowel enteroscopy are being used to detect lesions in the small bowel which were previously inaccessible without surgery.[14]

Endoscopic ultrasound (EUS) is the standard test to evaluate submucosal lesions of the gastrointestinal tract. In the gastric antrum, EUS can diagnose submucosal HP (pancreatic rests) ranging from 0.5 to 2 cm in diameter, and when combined with fine-needle aspiration, the cytological evaluation has a sensitivity of 80%–100%.[15]

There is no consensus about whether incidentally detected asymptomatic HP should be resected. Particularly, when it is detected intraoperatively, the judgment is difficult as there is no preoperative informed consent for its resection. Since the possibility of malignant transformation is extremely low and as it grows very slowly, preventive resection has been reported to be unnecessary.[16]

Surgical resection of HP should be performed in symptomatic patients after more common causes of abdominal complaints such as peptic ulcer disease, gastroesophageal reflux disease, and biliary disease have been ruled out. In our case, jejunal HP was detected incidentally during exploratory laparotomy for other disease, and the lesion was resected out of curiosity to identify the pathology.


  Conclusion Top


Although HP is not uncommon, we are reporting a rare case of subserosal jejunal HP incidentally found during laparotomy for other cause. In light of this incidental finding, we conclude that despite of rarity of lesion, it should be considered in the differential diagnosis of any incidentally found subserosal/serosal nodule along the gastrointestinal tract.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Dolan RV, ReMine WH, Dockerty MB. The fate of heterotopic pancreatic tissue. A study of 212 cases. Arch Surg 1974;109:762-5.  Back to cited text no. 1
    
2.
de Castro Barbosa JJ, Dockerty MB, Waugh JM. Pancreatic heterotopia; Review of the literature and report of 41 authenticated surgical cases, of which 25 were clinically significant. Surg Gynecol Obstet 1946;82:527-42.  Back to cited text no. 2
    
3.
Rasalkar D, Paunipagar B, Chan A. Heterotopic pancreas in the jejunum. J Hong Kong Col Radiol 2010;13:73-5.  Back to cited text no. 3
    
4.
Eisenberger CF, Gocht A, Knoefel WT, Busch CB, Peiper M, Kutup A, et al. Heterotopic pancreas – Clinical presentation and pathology with review of the literature. Hepatogastroenterology 2004;51:854-8.  Back to cited text no. 4
    
5.
Barkolias C, Orfanos N, Kalles V, Georgiou G, Papapanagiotou I, Flessas I, et al. Ectopic pancreatic tissue located in the subserosa of the jejunum: A case report. OA Case Rep 2013;2:58.  Back to cited text no. 5
    
6.
Armstrong CP, King PM, Dixon JM, Macleod IB. The clinical significance of heterotopic pancreas in the gastrointestinal tract. Br J Surg 1981;68:384-7.  Back to cited text no. 6
    
7.
Ormarsson OT, Gudmundsdottir I, Mårvik R. Diagnosis and treatment of gastric heterotopic pancreas. World J Surg 2006;30:1682-9.  Back to cited text no. 7
    
8.
Gaspar FA, Campos TJ, Fernandez BJ, Castells TE, Ruíz RJ, Gomez PJ, et al. Pancreatic ectopias. Revista española de las enfermedades del aparato digestivo 1973;39:255-68.  Back to cited text no. 8
    
9.
Chandan VS, Wang W. Pancreatic heterotopia in the gastric antrum. Arch Pathol Lab Med 2004;128:111-2.  Back to cited text no. 9
    
10.
Pang LC. Pancreatic heterotopia: A reappraisal and clinicopathologic analysis of 32 cases. South Med J 1988;81:1264-75.  Back to cited text no. 10
    
11.
Hirasaki S, Kubo M, Inoue A, Miyake Y, Oshiro H. Jejunal small ectopic pancreas developing into jejunojejunal intussusception: A rare cause of ileus. World J Gastroenterol 2009;15:3954-6.  Back to cited text no. 11
    
12.
Hirasaki S, Tanimizu M, Moriwaki T, Nasu J. Acute pancreatitis occurring in gastric aberrant pancreas treated with surgery and proved by histological examination. Intern Med 2005;44:1169-73.  Back to cited text no. 12
    
13.
Guillou L, Nordback P, Gerber C, Schneider RP. Ductal adenocarcinoma arising in a heterotopic pancreas situated in a hiatal hernia. Arch Pathol Lab Med 1994;118:568-71.  Back to cited text no. 13
    
14.
Christodoulidis G, Zacharoulis D, Barbanis S, Katsogridakis E, Hatzitheofilou K. Heterotopic pancreas in the stomach: A case report and literature review. World J Gastroenterol 2007;13:6098-100.  Back to cited text no. 14
    
15.
Chak A, Canto MI, Rösch T, Dittler HJ, Hawes RH, Tio TL, et al. Endosonographic differentiation of benign and malignant stromal cell tumors. Gastrointest Endosc 1997;45:468-73.  Back to cited text no. 15
    
16.
Watanabe M, Shiozawa K, Kishimoto Y, Arai T, Nakano S, Kikuchi Y, et al. Heterotopic pancreas of the jejunum incidentally detected by preoperative abdominal CT: Report of two cases and review of the literature. Case Rep Gastroenterol 2012;6:576-82.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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