CT appearance of ectopic pancreas: a case report

Use of computed tomography for distinguishing heterotopic pancreas from gastrointestinal stromal tumor and leiomyoma

PURPOSE

To determine whether morphologic features and semiquantitative parameters of computed tomography (CT) could be used to distinguish heterotopic pancreas from gastrointestinal stromal tumor (GIST) and leiomyoma.

METHODS

This retrospective study evaluated CT images of heterotopic pancreases (n = 28), GISTs (n = 57), and leiomyomas (n = 26) located in the upper gastrointestinal tract. Morphologic imaging features of lesions were analyzed, including location, contour, margin, attenuation, growth pattern, enhancement type, enhancement degree, enlarged vessels feeding or draining the mass, hyperenhancement of the overlying mucosa, low intralesional attenuation, calcification, and a duct-like structure. Semiquantitative parameters included long diameter (LD), short diameter (SD), LD/SD ratio, and lesion and aorta CT values during plain CT (Lp and Ap), arterial phase (La and Aa), and venous phase (Lv and Av). Diagnostic performance of these findings and parameters were evaluated by receiver operating characteristic (ROC) analysis.

RESULTS

Morphologic CT findings (including lesion contour, margin, attenuation, growth pattern, enhancement type, and enhancement degree) and semiquantitative parameters except for LD/SD were demonstrated to be significant for differentiating heterotopic pancreas from GIST and leiomyoma (all P < 0.01). Of these, location, low intralesional attenuation, duct-like structure and LD, SD, Lv, and Sv values showed good diagnostic performance with the areas under curve (AUC) higher than 0.70. The presence of a duct-like structure demonstrated the best diagnostic ability with AUC of 0.929 [95% confidence interval (CI) 0.864-0.969], sensitivity of 5.7% (95% CI 67.3-96.0), and specificity of 100% (95% CI 95.7-100), respectively. When the three morphologic features (location, low intralesional attenuation, duct-like structure) were used in combination, the AUC was improved to 0.980 (95% CI 0.952-1).

CONCLUSION

CT features, especially the morphologic features, could be used to differentiate heterotopic pancreas from GIST and leiomyoma in the upper gastrointestinal tract and, thus, provide a more accurate method for non-invasive preoperative diagnosis. Additionally, the presence of a duct-like structure demonstrated to be a reliable indicator for heterotopic pancreas among the morphologic and semiquantitative CT features.

Mesenteric heterotopic pancreas in a pediatric patient: A case report and review of literature

Heterotopic pancreas (HP) is a congenital anomaly defined as pancreatic tissue that has no contact with the orthotopic pancreas and its own duct system and vascular supply. The most common locations of HP are the upper gastrointestinal tract, specifically, the stomach, duodenum, and proximal jejunum. Involvement of the mesentery is rare. Here, we describe a rare case of mesenteric heterotopic pancreas (MHP) in a 12-year-old girl who presented with acute abdomen. The patient underwent emergency laparotomy, and the mass and adjacent small bowel were resected. Results of the postoperative histopathologic examination confirmed the diagnosis of MHP. Observation of the patient for 12 mo postoperatively showed no evidence of recurrence. Preoperative diagnosis of HP is difficult, even in a symptomatic patient. Increased awareness and understanding of the image characteristics of MHP will aid in correct preoperative diagnosis and appropriate patient management.

Acute Clinical Manifestation of Mesenteric Heterotopic Pancreatitis: A Pre- and Postoperative Confirmed Case

Heterotopic pancreas is a relatively uncommon congenital anomaly, defined as pancreatic tissue in ectopic sites without an anatomic and vascular continuity with the main body of the pancreas. We report the case of a 58-year-old woman who was admitted to the hospital with the clinical suspicion of a mild, acute pancreatitis. Computed tomography, magnetic resonance imaging, transabdominal ultrasound, and endoscopic ultrasound revealed a normal orthotopic pancreas and the suspicion of a large heterotopic pancreas in the small bowel mesentery with signs of acute inflammation. The diagnosis of mesenteric heterotopic pancreatitis was preoperatively confirmed by endoscopic ultrasound-guided fine-needle aspiration and consequently histologically established after surgical resection.

A stubborn anemia caused by ectopic pancreas bleeding in the jejunum revealed by capsule endoscopy

Ectopic pancreas is extremely rare in clinical setting. Meanwhile, a stubborn anemia without obvious dark bloody stool due to ectopic pancreas diagnosed by capsule endoscopy has not been reported. We reported a case of an ectopic pancreas inducing obscure gastrointestinal bleeding in a 70-year-old woman presenting as stubborn anemia, which was diagnosed by capsule endoscopy. The patient recovered well after resection the lesion. Diagnosis of ectopic pancreas is extremely difficult with conventional techniques. Endoscopists should pay more attention to the ectopic pancreas as a rare differential consideration for occult intestinal bleeding.

Heterotopic pancreas of the jejunum: associations between CT and pathology features. ACTA ACUST UNITED AC. 2015;40:38-45. [PMID: 24934475 DOI: 10.1007/s00261-014-0177-y]

PURPOSE

To investigate the computed tomography (CT) features of heterotopic pancreas of the jejunum (HPJ) and to assess their associations with HPJ pathology features.

METHODS

In this retrospective series analysis, two radiologists reviewed the CT images of 17 patients with surgically proven HPJ in order to determine in consensus the location, long diameter, margin, shape, contour, and growth pattern of the lesions, the presence of a duct-like structure, the lesion enhancement patterns, including the homogeneity, and the degree of contrast enhancement compared with that of the main pancreas. The pathology features of the surgical specimens were reviewed and their associations with the CT features were assessed.

RESULTS

On CT, the HPJs typically appeared as a small (<3 cm), well-defined, ovoid or flat-shaped mass in the proximal jejunum with multiple and tiny lobulations. The growth pattern varied and the duct-like structure was rarely visible. The HPJs mostly appeared to be homogeneous and exhibited hyper- or isoattenuation compared to the main pancreas in the arterial and portal phases. However, these enhancement patterns varied slightly depending on the microscopic composition of the lesions (i.e., acinar vs. ductal predominance). Most HPJs comprised histologically of large acini, some ducts, and small islet cells, and had ductal communication with the jejunum.

CONCLUSIONS

HPJs typically manifested as small, well-defined, ovoid or flat-shaped, homogeneous, and well-enhancing masses with a microlobulated contour in the proximal jejunum on CT, and their enhancement patterns associated with their microscopic composition. The pathology features of HPJs generally mimic those of the normal pancreas.

A retroperitoneal neuroendocrine tumor in ectopic pancreatic tissue

Ectopic pancreas is the relatively uncommon presence of pancreatic tissue outside the normal location of the pancreas. We report a case of abdominal pain due to retroperitoneal neuroendocrine tumor arising from heterotopic pancreatic tissue between the duodenal wall and the head of the pancreas. Patient underwent surgical enucleation of the tumor.

Heterotopic pancreas in excluded stomach diagnosed after gastric bypass surgery

Background

Heterotopic pancreas is defined as finding of pancreatic tissue without anatomic and vascular continuity with the normal pancreas. Heterotopic pancreas is a rare condition difficult to diagnose and with controversial clinical management.

Case presentation

We describe a 43 year old female patient previously submitted to laparoscopic gastric bypass for primary treatment of morbid obesity; 5 years later, the patient was discovered to have a mass in the antrum of the excluded stomach that was found to be heterotopic pancreatic tissue. Before gastric bypass surgery, the presence of the pancreatic mass in the gastric wall was unnoticed in the imagiologic records.

Conclusion

This is the first reported case of pancreatic heterotopy diagnosed in the excluded stomach after gastric bypass. A putative role of incretin hormones in mediating pancreatic cell hyperplasia of heterotopic pancreatic remnants should be considered an additional hypothesis that requires further research.

Gastric subepithelial masses: evaluation of multidetector CT (multiplanar reconstruction and virtual gastroscopy) versus endoscopic ultrasonography

OBJECTIVES

To assess the role of multidetector computed tomography (MDCT) with multiplanar reconstruction (MPR) and virtual gastroscopy (VG) for detection and differentiation of gastric subepithelial masses (SEMs) by comparison with endoscopic ultrasonography (EUS).

METHODS

Forty-one patients with a suspected SEM were evaluated using EUS and MDCT. MDCT findings were analyzed based on the consensus of two radiologists who were blinded to the EUS findings. The analysis of the CT features included the location, size, and contours of the tumor, the presence of central dimpling, as well as the growth pattern, enhancement pattern, and enhancement degree. The long diameter (LD) and the short diameter (SD) of each lesion were measured and the LD/SD ratios were calculated. EUS and MDCT results were compared with histopathology for the pathologically proven lesions. For the non-pathologically proven lesions, MDCT results were compared with EUS.

RESULTS

Among the 41 patients, 34 SEMs were detected using EUS. For the detection of SEMs with MDCT, a sensitivity of 85.3%, a specificity of 85.7%, a positive predictive value of 96.7%, and a negative predictive value of 54.5% were calculated. The overall accuracy of MDCT for detecting and classifying the SEMs was 85.3 and 78.8%, respectively.

CONCLUSIONS

MDCT with MPR and VG is a valuable method for the evaluation of SEMs. Specific MDCT criteria for various SEMs may be helpful in making an accurate diagnosis.

Ectopic pancreas presenting with pancreatitis and a mesenteric mass

Ectopic pancreas is defined by the presence of abnormally situated pancreatic tissue that lacks contact with normal pancreas and possesses its own duct system and vascular supply. Ectopic pancreas in the gastrointestinal tract is not uncommon. Moreover, there are several reported cases of adult ectopic pancreatitis in the literature, but to date, only two cases of pediatric ectopic pancreatitis have been reported. We describe a 15-year-old female with acute right upper quadrant pain and elevated serum lipase and amylase, in whom the radiological diagnosis was mesenteric soft tissue mass with adjacent inflammatory changes. The surgical pathology diagnosis, however, was mesenteric ectopic pancreas complicated by pancreatitis. We advocate for ectopic pancreatitis to be considered in a pediatric patient with acute abdominal pain, laboratory findings consistent with pancreatitis, and imaging findings of a mesenteric mass and normal orthotopic pancreas.

Upper gastrointestinal tract heterotopic pancreas: findings from CT and endoscopic imaging with histopathologic correlation

OBJECTIVE

To evaluate and describe computed tomographic (CT) and endoscopic (ES) imaging findings in patients with pathologically confirmed upper gastrointestinal (GI) tract heterotopic pancreas (HP).

METHODS

Findings from imaging examinations in 11 patients with pathologically confirmed HP were retrospectively reviewed (CT images obtained from 11 patients and ES images from 6 patients were available for review). Two radiologists evaluated lesion location, size, shape and border as well as growth pattern, enhancement pattern, enhancement grade and number of tumors. The presence of surface dimpling, prominent enhancement of overlying mucosa, and low intralesional attenuation were also evaluated.

RESULTS

HP in the upper GI tract showed typical features in CT imaging: submucosal masses, ill-defined borders, endoluminal growth patterns, bright enhancement similar to the normal pancreas, surface dimpling and low intralesional attenuation. Endoscopic photographs manifested an endoluminal, ill-defined, submucosal mass in the upper GI tract wall, typically with central umbilication. The LD (long diameter)/SD (short diameter) ratios were found to be significantly different between HP in the stomach and HP in the duodenum (P<.05 for each finding). In addition, HP in the duodenum tended to be small and round.

CONCLUSIONS

HP exhibits typical pancreatic pathologic features. Images showed characteristic features in CT imaging: submucosal masses, ill-defined lesions with an endoluminal growth pattern, bright enhancement similar to the normal pancreas, surface dimpling and low intralesional attenuation. ES imaging showed an endoluminal, ill-defined, submucosal mass, typically with central umbilication.

Cystic lesions of the gastrointestinal tract: multimodality imaging with pathologic correlations

The cystic lesions of the gastrointestinal (GI) tract demonstrate the various pathologic findings. Some lesions may present a diagnostic challenge because of non-specific imaging features; however, other lesions are easily diagnosed using characteristic radiologic features and anatomic locations. Cystic masses from the GI tract can be divided into several categories: congenital lesions, neoplastic lesions (cystic neoplasms, cystic degeneration of solid neoplasms), and other miscellaneous lesions. In this pictorial review, we describe the pathologic findings of various cystic lesions of the GI tract as well as the radiologic features of GI cystic lesions from several imaging modalities including a barium study, transabdominal ultrasound (US), computed tomography (CT), and magnetic resonance (MR) imaging.

Retroperitoneal ectopic pancreas: imaging findings

Ectopic pancreas is relatively uncommon and usually occurs in the stomach or duodenum. Retroperitoneal ectopic pancreas has not previously been documented. We report the case of a 48-year-old man with retroperitoneal ectopic pancreas that imitated bilateral adrenal tumours on ultrasound and MRI. Subsequent CT-guided biopsies confirmed an ectopic pancreas. The lesions remained stable during follow-up for 7 years. In retrospect, the similarity in signal intensities and enhancement pattern between the retroperitoneal masses and the pancreas may have been a clue to the diagnosis of this rare entity.

Ectopic pancreas: CT findings with emphasis on differentiation from small gastrointestinal stromal tumor and leiomyoma

PURPOSE

To describe the computed tomographic (CT) findings of ectopic pancreas and to identify the features that differentiate it from other similarly manifesting gastric submucosal tumors such as gastrointestinal stromal tumor (GIST) and leiomyoma, which are the most common gastrointestinal submucosal tumors.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board and did not require informed consent. CT images of pathologically proved ectopic pancreases (n = 14), GISTs (n = 33), and leiomyomas (n = 7) in the stomach and duodenum were retrospectively reviewed. Analysis of the CT findings included evaluation of the location, contour, growth pattern, border, enhancement pattern, and enhancement grade of the tumor, as well as the presence of surface dimpling, prominent enhancement of overlying mucosa, and low intralesional attenuation. The attenuation of each lesion, the long diameter (LD), the short diameter (SD), and the LD/SD ratio were measured. Among these findings, statistically significant variables were determined by using the chi(2) test (to compare the categoric variables), the Student t test (for quantitative analysis), and the receiver operating characteristic curve (to determine the optimal cutoff of the LD/SD ratio).

RESULTS

The typical location (prepyloric antrum and duodenum), endoluminal growth pattern, ill-defined border, prominent enhancement of overlying mucosa, and an LD/SD ratio of greater than 1.4 were found to be significant for differentiating ectopic pancreas from other tumors (P < .05 for each finding). When at least two of these five criteria were used in combination, the sensitivity and specificity for diagnosing ectopic pancreas were 100% (14 of 14) and 82.5% (33 of 40), respectively. When four of these criteria were used, a sensitivity of 42.9% and a specificity of 100% were achieved.

CONCLUSION

By using specific CT criteria, ectopic pancreas can be differentiated from small GIST or leiomyoma with a high degree of accuracy.

[Heterotopic pancreas in the gallbladder. Diagnosis, therapy, and course of a rare developmental anomaly of the pancreas]

Ectopic pancreas is a rare entity but the second most prevalent pancreatic anomaly. Heterotopic pancreas is defined as the presence of pancreatic tissue without any anatomic or vascular continuity with the main body of the pancreas. Its aetiology is not clearly established. In 1916, Poppi published for the first time evidence of heterotopic pancreas in the gallbladder. A review of the literature up to the present showed only 28 more cases worldwide of ectopic pancreas in the gallbladder. Aberrant pancreas is incidentally discovered in 2% of autopsies and has been estimated to occur once in every 500 upper abdominal explorations. Ninety per cent of ectopic pancreas is found in the stomach, duodenum, and jejunum. Mostly it is asymptomatic and benign. For this reason, therapy is indicated only in patients with symptoms such as pyloric obstruction, bleeding, and malignant transformation. Surgical resection or endoscopic mucosal resection as a newer method are recommended.

Laparoscopic Wedge Resection for Gastric Ectopic Pancreas

Ectopic pancreas is pancreatic tissue found outside the usual anatomic location of the pancreas. It is often an incidental finding in clinical practice and can be found at different sites in the gastrointestinal tract. Although usually a silent anomaly, it may become clinically evident when complicated by pathologic changes such as inflammation, bleeding, obstruction, and malignant transformation. We describe a case of ectopic pancreas located in the stomach, treated with a laparoscopic approach that permitted isolation and complete resection of the lesion. The patient was discharged without complications and without recurrence of symptoms.

Massive gastrointestinal bleeding caused by ectopic pancreas mimicking jejunal tumor

BACKGROUND

Ectopic pancreas is usually an incidental finding at surgery or autopsy and rarely produces clinical symptoms. But it is capable of producing symptoms, depending on its location, size and involvement of the overlying mucosa.

CASE REPORT

We report a case with massive gastrointestinal bleeding from ectopic pancreas mimicking jejunal tumor, confirmed by emergency operation. A 40-year-old male was admitted to Chonnam National University Hospital with a 2-day history of melena. A technetium-99m-labeled RBC scan showed massive radioactivity in loops of small bowel due to active bleeding. Superior mesenteric angiography revealed a hypervascular stained mass supplied by proximal jejunal branch. A computed tomographic scan of abdomen revealed an enhancing mass in the proximal jejunum. At emergency operation, bleeding from the center of the mass was found situated approximately 30 cm from the Treitz ligament. Segmental resection of the involved jejunum and end-to-end anastomosis were performed. Histologic examination of resected specimen revealed an ectopic pancreas.

CONCLUSION

So far, there have been no case reports of massive gastrointestinal bleeding from ectopic pancreas mimicking jejunal tumor as described in our case. In every patient in whom ectopic pancreas can definitely be seen to cause clinical symptoms including gastrointestinal bleeding, the lesion should be excised.