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Mirzaie S, Hu TX, Yang L, Lawson KL, Girgis MD. Gastric outlet obstruction caused by heterotopic pancreas in a patient with alcohol use disorder. Int J Surg Case Rep 2023; 105:107974. [PMID: 36933407 PMCID: PMC10034423 DOI: 10.1016/j.ijscr.2023.107974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 02/28/2023] [Accepted: 03/11/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Heterotopic Pancreas (HP) is defined by the presence of pancreatic tissue in an anatomically distinct location from the main pancreas. While often clinically silent, it may present symptomatically. If located in the gastric antrum, HP may cause gastric outlet obstruction (GOO). The objective of this paper is to present a rare case of HP in the gastric antrum causing GOO. CASE PRESENTATION Herein, we report a 43-year-old man who presented with abdominal pain and non-bilious emesis in the setting of COVID-19 infection and alcohol consumption. During the initial workup, computed-tomography (CT) was non-specific but demonstrated GOO, concerning for cancer. Cold forceps biopsies taken during esophagogastroduodenoscopy (EGD) confirmed benign HP. Since the patient was symptomatic from gastric outlet compression, he underwent resection via laparoscopic distal gastrectomy and Billroth II gastrojejunostomy. At 1-month postoperative follow-up, the patient recovered uneventfully. We hypothesized that GOO by HP in this case may have been associated with cumulative effects of alcohol consumption and COVID-19 infection on the ectopic tissue. CLINICAL DISCUSSION HP is rare and difficult to diagnose preoperatively. When located in gastric antrum, HP can cause GOO, mimicking gastric malignancy. Combination of EGD/EUS, biopsy/FNA, and surgical resection are necessary to definitively make the diagnosis. Finally, it is important to consider that heterotopic pancreatitis or structural changes in HP may occur due to classic pancreatic stressors like alcohol and viral infections. CONCLUSION HP may cause GOO presenting with non-bilious emesis and abdominal pain, mistaken for malignancy on CT imaging.
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Affiliation(s)
- Sarah Mirzaie
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA.
| | - Theodore X Hu
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA
| | - Lu Yang
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA
| | - Katy L Lawson
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine and Ronald Reagan UCLA Medical Center, University of California, Los Angeles, CA 90095, USA
| | - Mark D Girgis
- David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Department of Surgery, Los Angeles, CA, USA
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Kawaguchi S, Murakami A, Nishida M. Duodenal Heterotopic Pancreas with a Large Retention Cyst: A Case Report and Literature Review. Intern Med 2023; 62:723-727. [PMID: 35871586 PMCID: PMC10037013 DOI: 10.2169/internalmedicine.0227-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 75-year-old man was referred to our hospital with a suspected pancreatic cyst. Imaging tests revealed a 3-cm cystic lesion located ventrally in the duodenal bulbus, which was suspected to be a duplication cyst with its muscularis propria contiguous to that of the duodenum. One year later, the cyst grew to 6 cm due to intracystic hemorrhaging; therefore, surgery was performed. Histopathology revealed a heterotopic pancreas (HP) in the duodenal wall. The diagnosis was a large, non-malignant retention cyst. Inflammation due to impaired outflow of pancreatic juice from the HP was identified as the cause of cyst enlargement.
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Affiliation(s)
- Shinya Kawaguchi
- Department of Gastroenterology, Shizuoka General Hospital, Japan
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Gastric Ectopic Pancreas With Pseudocyst Formation Causing Gastric Outlet Obstruction. ACG Case Rep J 2023; 10:e00988. [PMID: 36788791 PMCID: PMC9916032 DOI: 10.14309/crj.0000000000000988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/17/2023] [Indexed: 02/11/2023] Open
Abstract
Ectopic pancreas is a rare entity referring to the presence of pancreatic tissue at an anatomic location distinct from the pancreas. Ectopic pancreatic lesions in the stomach present a diagnostic challenge because the lack of distinguishing imaging and endoscopic features make them difficult to differentiate from other types of submucosal lesions. We report a case of ectopic pancreas presenting as a gastric antral mass with a unique combination of rare complications: chronic pancreatitis and pseudocyst formation causing gastric outlet obstruction. This case highlights complications that can occur from ectopic pancreatic lesions and the challenges of diagnosing ectopic pancreas.
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LeCompte MT, Mason B, Robbins KJ, Yano M, Chatterjee D, Fields RC, Strasberg SM, Hawkins WG. Clinical classification of symptomatic heterotopic pancreas of the stomach and duodenum: A case series and systematic literature review. World J Gastroenterol 2022; 28:1455-1478. [PMID: 35582670 PMCID: PMC9048474 DOI: 10.3748/wjg.v28.i14.1455] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/11/2021] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Heterotopic pancreas (HP) is an aberrant anatomic malformation that occurs most commonly in the upper gastrointestinal tract. While the majority of heterotopic pancreatic lesions are asymptomatic, many manifest severe clinical symptoms which require surgical or endoscopic intervention. Understanding of the clinical manifestations and symptoms of HP is limited due to the lack of large volume studies in the literature. The purpose of this study is to review symptomatic cases at a single center and compare these to a systematic review of the literature in order to characterize common clinical manifestations and treatment of this disease.
AIM To classify the common clinical manifestations of heterotopic pancreas.
METHODS A retrospective review was conducted of pathologic samples containing heterotopic pancreas from 2000-2018. Review was limited to HP of the upper gastrointestinal tract due to the frequency of presentation in this location. Symptomatic patients were identified from review of the medical records and clinical symptoms were tabulated. These were compared to a systematic review of the literature utilizing PubMed and Embase searches for papers pertaining to heterotopic pancreas. Publications describing symptomatic presentation of HP were selected for review. Information including demographics, symptoms, presentation and treatment were compiled and analyzed.
RESULTS Twenty-nine patient were identified with HP at a single center, with six of these identified has having clinical symptoms. Clinical manifestations included, gastrointestinal bleeding, gastric ulceration with/without perforation, pancreatitis, and gastric outlet obstruction. Systemic review of the literature yielded 232 publications detailing symptomatic cases with only 20 studies describing ten or more patients. Single and multi-patient studies were combined to form a cohort of 934 symptomatic patients. The majority of patients presented with abdominal pain (67%) combined with one of the following clinical categories: (1) Dyspepsia, (n = 445, 48%); (2) Pancreatitis (n = 260, 28%); (3) Gastrointestinal bleeding (n = 80, 9%); and (4) Gastric outlet obstruction (n = 80, 9%). The majority of cases (n = 832, 90%) underwent surgical or endoscopic resection with 85% reporting resolution or improvement in their symptoms.
CONCLUSION Heterotopic pancreas can cause significant clinical symptoms in the upper gastrointestinal tract. Better understanding and classification of this disease may result in more accurate identification and treatment of this malformation.
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Affiliation(s)
- Michael T LeCompte
- Department of Surgical Oncology, University of North Carolina, Raleigh, NC 27608, United States
| | - Brandon Mason
- Department of Radiology, Stillwater Medical Center, Stillwater, OK 74074, United States
| | - Keenan J Robbins
- Department of General Surgery, Washington University St. Louis, St. Louis, MO 63110-8109, United States
| | - Motoyo Yano
- Department of Radiology, Mayo Clinic, Phoenix, AZ 8505, United States
| | - Deyali Chatterjee
- Department of Pathology and Immunology, MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Ryan C Fields
- Department of Surgical Oncology, Washington University School of Medicine, St. Louis, MO 63110-8109, United States
| | - Steven M Strasberg
- Section of Hepatobiliary-Pancreatic and GI Surgery, Washington University St. Louis, St. Louis, MO 63110, United States
| | - William G Hawkins
- Section of Hepatobiliary-Pancreatic and GI Surgery, Washington University St. Louis, St. Louis, MO 63110, United States
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Nguyen TL, Kapur S, Schlack-Haerer SC, Gurda GT, Folkers ME. Unusual Tissue - Unusual Issue: Pancreatic Heterotopia Presenting as Gastric Outlet Obstruction. Case Rep Gastroenterol 2021; 15:338-343. [PMID: 33790723 PMCID: PMC7989796 DOI: 10.1159/000512427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022] Open
Abstract
Pancreatic heterotopia (PH) is a common, but typically small (<1 cm), incidental and asymptomatic finding; however, PH should be considered even for large and symptomatic upper gastrointestinal masses. A 27-year-old white woman presented with a 3-week history of burning epigastric pain, nausea, early satiety, and constipation. Physical examination revealed epigastric and right upper quadrant tenderness with normal laboratory workup, but imaging revealed a 5-cm, partly cystic mass arising from the gastric antrum with resulting pyloric stenosis and partial gastric outlet obstruction. Endoscopic ultrasound-guided fine needle aspiration revealed PH − an anomalous pancreatic tissue lying in a nonphysiological site. The patient ultimately underwent a resection and recovered uneventfully, with a complete pathologic examination revealing normal exocrine pancreatic tissue (PH type 2) without malignant transformation. We report a case of heterotopic pancreas manifesting as severe gastric outlet obstruction, in addition to a thorough diagnostic workup and surgical follow-up, in a young adult. Differential diagnoses and features that speak to benignity of a large, symptomatic mass lesion (PH in particular) are discussed.
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Affiliation(s)
- Thu L Nguyen
- Division of Medical Education, Department of Internal Medicine, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Shivani Kapur
- Division of Medical Education, Department of Internal Medicine, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Stephen C Schlack-Haerer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gundersen Health System, La Crosse, Wisconsin, USA
| | - Grzegorz T Gurda
- Department of Pathology, Gundersen Health System, La Crosse, Wisconsin, USA.,Gundersen Medical Foundation, Kabara Cancer Research Institute, La Crosse, Wisconsin, USA
| | - Milan E Folkers
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gundersen Health System, La Crosse, Wisconsin, USA
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Submucosal Tunneling Endoscopic Resection for the Management of Heterotopic Pancreas With Cystic Degeneration. ACG Case Rep J 2020; 7:e00419. [PMID: 32766361 PMCID: PMC7357709 DOI: 10.14309/crj.0000000000000419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/08/2020] [Indexed: 11/17/2022] Open
Abstract
Heterotopic pancreas is pancreatic tissue present outside of the normal location of the pancreas. In the presence of cystic degeneration, heterotopic pancreas is clinically significant because of the symptoms it causes and its physical resemblance to cancerous growth. A diagnosis of heterotopic pancreas is achieved with the aid of various endoscopic techniques for tissue removal. Submucosal tunneling endoscopic resection has proven successful for the resection of gastric subepithelial masses. We present a 53-year-old woman undergoing submucosal tunneling endoscopic resection for the resection of a subepithelial gastric cyst caused by heterotopic pancreas with cystic degeneration.
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Yokoyama K, Sato H, Sato Y, Watanabe J, Nakamura A, Terai S. Rare gastric outlet obstruction owing to ectopic pancreas: a case report and literature review. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:252. [PMID: 32309399 PMCID: PMC7154427 DOI: 10.21037/atm.2020.01.64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The ectopic pancreas is often observed in the gastrointestinal tract, and is typically asymptomatic. A 28-year-old woman was referred to our hospital following repeated vomiting after every meal. Following gastroscopy, contrast-enhanced computed tomography (CE-CT), and endoscopic ultrasonography (EUS), she was diagnosed with gastric outlet obstruction, also known as pyloric obstruction, caused by a giant submucosal cystic tumor. The condition was successfully treated with EUS-guided cystic drainage, and she was diagnosed with a cystic tumor originating from the ectopic pancreas. The tumor shrank following EUS-guided cystic drainage, and her obstructive symptoms resolved. In cases with overgrowth of the ectopic pancreas, the differential diagnosis of malignancy is important but challenging. Herein, we report a unique final pathology of this rare case and discuss the findings with a literature review.
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Affiliation(s)
- Kunihiko Yokoyama
- Division of Gastroenterology and Hepatology, Niigata prefectural Yoshida Hospital, Niigata, Japan.,Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Hiroki Sato
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Yuichi Sato
- Division of Gastroenterology and Hepatology, Niigata prefectural Yoshida Hospital, Niigata, Japan
| | - Jun Watanabe
- Division of Gastroenterology and Hepatology, Niigata prefectural Yoshida Hospital, Niigata, Japan
| | - Atsuo Nakamura
- Division of Gastroenterology and Hepatology, Niigata prefectural Yoshida Hospital, Niigata, Japan
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Niigata University Medical and Dental Hospital, Niigata, Japan
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Ectopic pancreatitis in the antral stomach causing gastric outlet obstruction: a case of successful resection. Clin J Gastroenterol 2019; 13:465-471. [PMID: 31758484 DOI: 10.1007/s12328-019-01073-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 11/14/2019] [Indexed: 10/25/2022]
Abstract
Ectopic pancreas is a congenital developmental anomaly that may be caused by embryologic errors. The pathogenetic details of ectopic pancreas remain unclear, but it has gradually been determined to originate at the gene level. DNA errors during embryological development cause ectopic pancreas. Ectopic pancreas is generally asymptomatic and harmless throughout the patient's entire life; in very rare cases, however, it can be symptomatic and harmful, causing pain, fever, bleeding, and other adverse effects. We herein report an unusual case involving a 52-year-old Japanese woman who presented with nausea and vomiting due to inflammation of an ectopic pancreas in the gastric antrum. Ectopic pancreatitis caused severe pyloric stenosis, and she was unable to ingest food or water even after admission to the internal medicine ward. Ectopic pancreatitis is a very rare clinical condition, but clinicians should be cautious of this uncommon disease in patients who develop gastric outlet obstruction without cancer or ulcers. The present case report is clinically significant because surgical treatment (distal partial gastrectomy) relieved the patient's serious distress rapidly and successfully after unsuccessful conservative treatments for acute ectopic pancreatitis. Antrectomy (distal partial gastrectomy) might be useful for ectopic pancreas, especially in case of gastric outlet obstruction due to the ectopic pancreatitis.
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Gastric Heterotopic Pancreas Presenting as Abdominal Pain with Acute and Chronic Pancreatitis in the Resected Specimen. Case Rep Gastrointest Med 2019; 2019:2021712. [PMID: 30956825 PMCID: PMC6431401 DOI: 10.1155/2019/2021712] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 01/21/2019] [Accepted: 02/18/2019] [Indexed: 11/18/2022] Open
Abstract
Heterotopic pancreas, also known as ectopic pancreas, is pancreatic tissue located outside the pancreatic parenchyma without vascular or ductal communication with the gland. Ectopic pancreas is rarely symptomatic, typically detected incidentally at surgery or autopsy. Eighty-five to 90% are in the upper GI tract, especially the gastric antrum. We report a 54-year-old man with symptomatic gastric heterotopic pancreas presenting as recurrent, initially undiagnosed, abdominal pain. Surgery revealed heterotopic pancreas including excretory ducts, acini, and islet cells. Evidence of acute pancreatitis was present, marked by inflammation and abscess formation. Chronic pancreatitis was diagnosed by fibrosis and dilated ducts containing proteinaceous material. Submucosal location with normal overlying mucosa on endoscopy increases risks of delayed or missed diagnosis. Complications include GI bleeding, acute or chronic pancreatitis, pancreatic necrosis, pseudocyst, gastric outlet obstruction, perforation, and, rarely, pancreatic carcinoma. This rare disorder mimics more common diseases. Low suspicion, nondiagnostic imaging or endoscopy contribute to frequent diagnostic delay.
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Li LM, Feng LY, Chen XH, Liang P, Li J, Gao JB. Gastric heterotopic pancreas and stromal tumors smaller than 3 cm in diameter: clinical and computed tomography findings. Cancer Imaging 2018; 18:26. [PMID: 30086800 PMCID: PMC6081935 DOI: 10.1186/s40644-018-0161-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/29/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Identifying gastric heterotopic pancreas and stromal tumors is difficult. Few studies have reported computed tomography (CT) findings for differentiating lesions less than 3 cm in diameter. In this study, we aimed to identify clinical characteristics and CT findings that can differentiate gastric heterotopic pancreatic lesions from stromal tumors less than 3 cm in diameter. METHODS A total of 132 patients with pathologically confirmed gastric heterotopic pancreas (n = 66) and stromal tumors (n = 66) were included. Each group was divided into primary (n = 50) and validation cohort (n = 16). Clinical characteristics and CT findings were retrospectively reviewed. CT findings included location, border, contour, growth pattern, enhancement pattern and grade, the enhancement value of tumor, enhancement ratio of tumor, and enhancement ratio of tumor to pancreas in venous phase. The findings in the two groups were compared using the Pearson χ2 test or Student t-test. Receiver operating characteristic curves were used to determine areas under the curve and optimal cut-offs. RESULTS Significant differences were observed between heterotopic pancreas and stromal tumors in the distribution of tumor location, border, contour (all P < 0.001), enhancement values (P < 0.001), enhancement ratios of tumors (P < 0.001), and enhancement ratios of tumors to pancreas (P < 0.001). No significant differences existed in growth pattern (P = 0.203). The area under the curve differed significantly between enhancement ratio of tumor to pancreas and enhancement ratio (P = 0.030). There were significant differences in above characteristics between two groups in validation cohort. CONCLUSIONS Heterotopic pancreas has characteristic CT features differentiating it from stromal tumors.
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Affiliation(s)
- Li-Ming Li
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Lei-Yu Feng
- Department of Internal Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Xiao-Hua Chen
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Pan Liang
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Jing Li
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China
| | - Jian-Bo Gao
- Department of Radiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan Province, China.
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