Journal of the Pancreas Open Access

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- (2009) Volume 10, Issue 4

Heterotopic Pancreas in the Jejunum Presenting as a Submucosal Lesion on Endoscopy

Surinder Singh Rana1, Deepak Kumar Bhasin1, Ritambhra Nada2,Rajesh Gupta3, Kartar Singh1

Departments of 1Gastroenterology, 2Histopathology, and 3Surgery, Post Graduate Institute of Medical Education and Research (PGIMER). Chandigarh, India

*Corresponding Author:
Surinder Singh Rana
Department of Gastroenterology, Postgraduate Institute of Medical
Education and Research (PGIMER), Chandigarh, India-160012
Phone: +91-172.274.9123
Fax: +91-172.274.4401
E-mail: drsurinderrana@yahoo.co.in, sonalisurinder@yahoo.co.in

Received:17 March 2009; Accepted: 15 May 2009

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Abstract

Context Ectopic pancreas can occur anywhere in the gastrointestinal tract with the stomach and small bowel being the most common sites. The endoscopic appearance of the ectopic pancreas in the small bowel has rarely been reported. Case report We report the case of a 45-year-old female with heterotopic pancreas in the jejunum who presented with recurrent episodes of abdominal pain and had a submucosal lesion on endoscopy. As she had undergone gastrojejunostomy in the past, the lesion in the jejunum could be diagnosed on endoscopy by entering the efferent loop. Conclusion Heterotopic pancreas should be considered when making a differential diagnosis of submucosal lesions in the small bowel.

KEYWORDS

Endoscopy; Gastric Bypass; Pancreas; Pancreatitis

INTRODUCTION

Heterotopic pancreas is a rare occurrence which can occur anywhere in the gastrointestinal tract with the stomach and the small bowel being the most common sites [1, 2]. In this entity, there is the presence of extra pancreatic tissue which does not have any vascular or anatomic relation with the pancreas. It is usually clinically silent and most of the lesions are diagnosed incidentally [1, 2]. We present the case of a 45-year-old female with heterotopic pancreas in the jejunum who presented with recurrent episodes of abdominal pain and had a submucosal lesion on endoscopy.

CASE REPORT

A 45-year-old female presented to us with complaints of recurrent episodes of abdominal pain of 2-year duration. The pain was periumbilical in location and colic-like in nature. The patient had undergone gastrojejunostomy for a complicated peptic ulcer 25 years previously. The clinical, hematological and biochemical investigations including serum amylase and lipase were normal. The skiagram of the abdomen and ultrasound of the abdomen were normal.

An upper gastrointestinal endoscopy revealed a normal esophagus and stomach. The pyloric channel was narrowed and the stoma of both the afferent and efferent loops of the gastrojejunostomy was normal. The afferent loop revealed a normal mucosa. In the efferent loop of the jejunum, 10 cm from the stoma, there was a submucosal lesion with no overlying ulcerations or hemorrhage (Figure 1). The endoscope was able to negotiate this lesion. The cytological examination of the endoscopic fine needle aspirate of the lesion did not reveal any abnormality. Contrast enhanced computed tomography (CECT) of the abdomen revealed the presence of a 2.5 cm hypodense intraluminal lesion in the efferent loop of the jejunum (Figure 2). The submucosal lesion in the jejunum was presumed to be acting as a lead point for recurrent intussusception and causing episodes of colic-like pain of the abdomen. Subsequently, surgical excision of the submucosal lesion was carried out. The histopathological examination revealed the presence of pancreatic tissue suggestive of an ectopic pancreatic crest in the jejunum (Figure 3). The patient had an uneventful post-operative course and is asymptomatic after 8 months of follow up.

pancreas-endoscopic-image-submucosal

Figure 1. Endoscopic image showing submucosal lesion in the efferent loop of the jejunum.

pancreas-cect-abdomen-hypodense

Figure 2. CECT of the abdomen showing a 2.5 cm hypodense lesion in the efferent loop of the jejunum (arrow).

pancreas-photomicrograph-epithelial

Figure 3. Photomicrograph shows sub epithelial pancreatic tissue (H&E x20).

DISCUSSION

Heterotopic pancreas, defined as pancreatic tissue which lacks anatomical and vascular communication with the normal pancreas, can occur anywhere in the gastrointestinal tract with the stomach being the most common site followed by the small bowel [1, 2]. These lesions are usually clinically silent but may become symptomatic because of complications such as pancreatitis, obstruction, bleeding or malignant transformation [1, 2]. The small bowel lesions are mostly diagnosed incidentally at surgery or autopsy [1, 2, 3]. In our case, the ectopic pancreas located in the small bowel presented with abdominal pain possibly because of recurrent episodes of intussusception. On endoscopy, the gastric heterotopic pancreas resembles a submucosal lesion which may have a central umbilication [1]. The endoscopic appearance of the jejunal heterotopic pancreas has rarely been reported [4].

Conflict of interest The authors have no potential conflicts of interest

References