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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 54  |  Issue : 6  |  Page : 244-246

Ectopic pancreas: An uncommon cause of recurrent abdominal pain


1 Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center; Department of Surgery, National Defense Medical Center, Division of General Surgery, Tri-Service General Hospital, Taipei, Taiwan
2 Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
3 Department of Surgery, National Defense Medical Center, Division of General Surgery, Tri-Service General Hospital, Taipei, Taiwan

Date of Submission17-Jun-2021
Date of Decision01-Sep-2021
Date of Acceptance29-Oct-2021
Date of Web Publication30-Nov-2021

Correspondence Address:
Kuo-Feng Hsu
Division of General Surgery, Department of Surgery, Tri-Service General Hospital, No. 325, Sec. 2, Cheng-Kung Road, Neihu 114, Taipei
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_129_21

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  Abstract 


Ectopic pancreas is a disease where pancreatic tissue occurs outside its normal anatomic location, without vascular continuity. Symptoms for this condition may depend on the localization of the ectopic tissue and originate from either mass effect or inflammation. The diagnosis of ectopic pancreas can be challenging due to its rarity and nonspecific symptoms. Herein, we report a case of recurrent abdominal pain diagnosed with gastric ectopic pancreas of uncommon size in an uncommon location. Upper gastrointestinal (GI) endoscopy revealed a large gastric polyp and endoscopic needle biopsy only identified normal gastric mucosa. However, computed tomography imaging revealed a protruding mass that, upon excision, was identified as ectopic pancreatic tissue. Two different pathological findings arose from two different sampling methods, leading us to the conclusion that ectopic pancreas should always be considered in the diagnosis of a GI tumor.

Keywords: Abdominal pain, ectopic pancreas, gastric tumor


How to cite this article:
Hsu FC, Hsu HN, Peng YJ, Hsu KF. Ectopic pancreas: An uncommon cause of recurrent abdominal pain. Formos J Surg 2021;54:244-6

How to cite this URL:
Hsu FC, Hsu HN, Peng YJ, Hsu KF. Ectopic pancreas: An uncommon cause of recurrent abdominal pain. Formos J Surg [serial online] 2021 [cited 2022 Jan 16];54:244-6. Available from: https://www.e-fjs.org/text.asp?2021/54/6/244/331634




  Introduction Top


Ectopic pancreas, which is defined as the presence of pancreatic tissue outside its normal anatomic location without vascular continuity, is a rare clinical condition. The ectopic tissue can be found in many organs, but mainly in the upper gastrointestinal (GI) tract. It can occur at any age, but mostly at the age of 30–50 years with a male predominance. Symptoms depend on the ectopic tissue's location, and may originate from tumor mass effect or inflammation. However, most of the patients are asymptomatic and diagnosed incidentally. Herein, we report a case of ectopic pancreas causing recurrent abdominal pain.


  Case Report Top


A 43-year-old male presented with recurrent intermittent abdominal dull pain in the past 2 months, which aggravated remarkably 2 days prior. There was no peritoneal sign. Gastric ulcer was suspected at local medical clinics. Symptom-relief agents such as antacids and pain killers were prescribed but were ineffective. He underwent upper GI endoscopy at a local clinic, which found a pedunculated gastric polyp about 3.5 cm in diameter [Figure 1]. The patient was referred to our hospital and admitted for further treatment. Physical examination, routine blood tests, electrocardiography (ECG), and X-ray series were unremarkable. Contrast-enhanced abdominal computed tomography (CT) revealed a protruding mass in the stomach [Figure 2]. Two endoscopic biopsies were performed and revealed normal gastric mucosa. However, differential diagnosis included diseases such as GI stromal tumors (GISTs), hamartomatous polyps, or leiomyomas. Injection-assisted endoscopic mucosal resection was attempted, but a nonlifting sign was noted, requiring further surgical intervention. Intraoperative upper GI endoscopy located the polyp in the posterior wall of the upper gastric corpus. After laparoscopic partial gastrectomy was performed, pathological analysis of the sample revealed ectopic pancreatic tissue with acinar glands and ducts. This differed from the initial biopsy result [Figure 3]. The postoperative course was uneventful, and the patient was discharged on postoperative day 3.
Figure 1: Upper gastrointestinal endoscopy revealed a gastric polypoid lesion over the posterior wall of the gastric corpus

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Figure 2: Abdominal computed tomography noted a protruding mass (arrow) over the gastric corpus

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Figure 3: H and E staining revealed ectopic pancreatic tissue occupying the submucosa and muscularis propria under normal gastric mucosa

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  Discussion Top


The pathogenesis of ectopic pancreas is unclear. However, the most likely theories are based on the rotation of the foregut during embryonal development. Fragments of pancreatic tissue separate from the main body and deposit to ectopic sites.[1] Another theory states that the endodermal tissues migrate to the submucosa during embryogenesis and develop into pancreatic tissue.[2] Therefore, ectopic pancreatic tissue may be found in different organs, including esophagus, stomach, small intestine, common bile duct, gallbladder, Meckel's diverticulum, and mesocolon. Nonetheless, stomach is the most frequent site, with a prevalence ranging from 38% to 86%.[3]

Symptoms of ectopic pancreas may relate to inflammation or mass effect. The most common symptoms are abdominal pain, nausea and vomiting, bleeding, and weight loss.[4] Other less common symptoms depend on the location of the ectopic pancreas, including obstruction, perforation, and intussusception. The ectopic tissue functions like normal pancreas tissue, thus the secretion of pancreatic enzyme and hormones may result in local or whole body effects.[5] In addition, the same pathologies that affect normal pancreas, such as pancreatitis, pseudocyst, and malignant transformation, can also affect ectopic tissue. However, an ectopic pancreas is usually asymptomatic and benign. In the case we present here, recurrent abdominal pain has been noted for 2 months. No remarkable abnormalities on ECG, blood tests, and chest plain film are found. Symptom is relieved after surgical intervention.

The diagnosis of ectopic pancreas is difficult because of its clinically silent characteristic and nonspecific symptoms. Thus, an endoscopy ultrasound (EUS) is performed due to its usefulness in detecting submucosal lesions. Matsushita et al. report that the ectopic tissue found by EUS tends to have a heterogeneous appearance and indistinct margin.[6] However, EUS has limited ability to differentiate an ectopic tissue from submucosal tumors. CT findings tend to have low specificity. On endoscopy, central dimpling or umbilication with mucus secretion from its central orifice may be a characteristic of ectopic pancreas. However, large GISTs, hamartomatous polyps, or leiomyomas may also present with a similar central necrosis. A pathological biopsy is necessary to confirm the presence of ectopic pancreatic tissue. However, biopsy results are usually inconclusive, and need a final histological confirmation based on the specimen after surgery or endoscopic resection.[7] Harold et al. report four cases of ectopic pancreatic tissue in the stomach, whereupon normal gastric mucosa are noted in two patients after endoscopic biopsy, and a nondiagnostic result in one.[8] In our case, the initial endoscopy biopsy showed a normal gastric mucosa, while the final diagnosis was ectopic pancreas. The reason for the different pathology results may be due to the following: (1) since an ectopic pancreas is usually located in the third or fourth layer of the gastric wall, the biopsy needle may not have reached the necessary depth and (2) the ectopic tissue was covered by a thick layer of normal gastric tissue, so the biopsy needle may have missed the main lesion.

Optimal treatment for asymptomatic ectopic pancreas has not been agreed upon. Conservative management that leaves the ectopic tissue in place seems reasonable if the aim is to prevent surgery-induced diabetes.[3] However, in patients with symptoms caused by ectopic pancreas, surgical excision is still the best course of action.[9] The diameter of heterotopic pancreatic tissue is generally about 1–2 cm,[9] but in our case, the diameter of the ectopic pancreas was larger (3.5 cm) and the tissue was located in the upper gastric corpus, differing from most of the published literature.[10] Therefore, an ectopic pancreas should always be considered in the differential diagnosis of a GI polyp or tumor, even if presenting with uncommon size and location.


  Conclusion Top


Ectopic pancreatic tissue can be found throughout the body but is mostly located in the stomach.

Despite the modern imaging tools, diagnosis of an ectopic pancreas remains to be excision of the lesion and pathologic examination of the specimen. Regardless of the location of the lesion, an ectopic pancreas should be included in the differential diagnosis of GI tract polyp or tumor. Resection of the lesion is still the most effective treatment for symptomatic patients.

Ethical approval

All procedures performed in this study involving human participant were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Emerson L, Layfield LJ, Rohr LR, Dayton MT. Adenocarcinoma arising in association with gastric heterotopic pancreas: A case report and review of the literature. J Surg Oncol 2004;87:53-7.  Back to cited text no. 1
    
2.
Park E, Kim H, Jung KW, Chung JH. Heterotopic pancreas in omphalomesenteric duct remnant results in persistent umbilical discharge. Korean J Pathol 2014;48:323-6.  Back to cited text no. 2
    
3.
Chiriatti E, Kuczma P, Galasso D, Koliakos E, Pezzetta E, Martinet O. Intramural ectopic pancreatic tissue of the stomach: A case report of an uncommon origin of a non-cancerous gastric tumour. Int J Surg Case Rep 2020;73:48-51.  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.
Filip R, Walczak E, Huk J, Radzki RP, Bieńko M. Heterotopic pancreatic tissue in the gastric cardia: A case report and literature review. World J Gastroenterol 2014;20:16779-81.  Back to cited text no. 5
    
6.
Matsushita M, Hajiro K, Okazaki K, Takakuwa H. Gastric aberrant pancreas: EUS analysis in comparison with the histology. Gastrointest Endosc 1999;49:493-7.  Back to cited text no. 6
    
7.
Agale SV, Agale VG, Zode RR, Grover S, Joshi S. Heterotopic pancreas involving stomach and duodenum. J Assoc Physicians India 2009;57:653-4.  Back to cited text no. 7
    
8.
Harold KL, Sturdevant M, Matthews BD, Mishra G, Heniford BT. Ectopic pancreatic tissue presenting as submucosal gastric mass. J Laparoendosc Adv Surg Tech A 2002;12:333-8.  Back to cited text no. 8
    
9.
Yuan Z, Chen J, Zheng Q, Huang XY, Yang Z, Tang J. Heterotopic pancreas in the gastrointestinal tract. World J Gastroenterol 2009;15:3701-3.  Back to cited text no. 9
    
10.
Yie M, Jang K, Kim M, Lee IJ, Yang DH, Jun SY, et al. Synchronous ectopic pancreases in the cardia and antrum of the stomach: A case report. J Korean Soc Radiol 2010;63:161.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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