For citation purposes: Barkolias C, Orfanos N, Kalles V, Georgiou G, Papapanagiotou I, Flessas I, Vrakopoulou GZ, Kaklamanos I, Goutas N, Mariolis-Sapsakos T. Ectopic pancreatic tissue located in the subserosa of the jejunum: A case report. OA Case Reports 2013 Aug 08;2(6):58.

Case Report

 
Surgery

Ectopic pancreatic tissue located in the subserosa of the jejunum: a case report

C Barkolias1, N Orfanos1, V Kalles2*, G Georgiou1, I Papapanagiotou1, I Flessas1, GZ Vrakopoulou1, I Kaklamanos1, N Goutas1, T Mariolis-Sapsakos2
 

Authors affiliations

(1) Department of General Surgery, Evgenidion Hospital, National and Kapodistrian University of Athens, Athens, Greece

(2) Anatomy Laboratory, School of Nursing, National and Kapodistrian University of Athens, Athens, Greece

* Corresponding author E-mail: vassilis_kalles@yahoo.com

Abstract

Introduction

Ectopic pancreas is defined as a pancreatic tissue in an abnormal location with no ductal, anatomical, neuronal or vascular communication with the main body of the pancreas. The incidence of heterotopic pancreas in autopsy studies is approximately 0.6%–15%, while the clinical incidence is 1 in 500 laparotomies. Ectopic pancreatic tissue can be present anywhere along the gastrointestinal tract. This paper discusses a case of ectopic pancreatic tissue located in the subserosa of the jejunum.

Case report

We present the case of a 53-year-old woman where a sigmoid resection for chronic, symptomatic diverticular disease was performed and incidentally, a 2 × 3 cm tumour was found in the jejunum. The histological study reported a subserosal heterotopic pancreatic tumour. The patient post-operatively remained asymptomatic and was dismissed on the 6th post-operative day.

Conclusion

In 75% of the cases, the ectopic pancreatic tissue is located in the submucosa. However, around 13% of these tumours will be found to be in the subserosa. This case is of great interest because of the subserosal location of the tumour.

Introduction

Ectopic pancreas is defined as a pancreatic tissue in an abnormal location with no ductal, anatomical, neuronal, vascular communication with the main body of the pancreas[1,2]. The incidence of heterotopic pancreas in autopsy studies is approximately 0.55%–13.7% and as low as 0.2% in laparotomies[3,4,5].

The ectopic pancreatic tissue can be present anywhere along the gastrointestinal tract[1,3,4,5,6,7]. Most frequently, it is located in the stomach, the duodenum, the proximal jejunum or the Meckel's diverticulum[8,9]. Rarely, it is seen in the ileum, the gallbladder, the bile ducts, the splenic hilum, the umbilicus and the liver[10,11,12]. The present report describes a rare case where the ectopic pancreatic tissue was located in the jejunum as a subserosal tumour.

Case report

A 53-year-old woman presented in our hospital for an elective sigmoidectomy due to chronic diverticulitis. The physical examination did not reveal any abnormal findings. Laboratory exams were normal [WBC of 8.4 × 103/μL (reference range: 5–10 × 10³/μL), neutrophils of 62% (reference range: 40–80%), a C-reactive protein equal to 2.6 mg/L (reference range: <5 mg/L), ESR equal to 24 mm/h (reference range: 20–30 mm/h)]. As well, all other laboratory values, including amylase and lipase, were within the reference limits. The preoperative ultrasonography study of the abdomen, the endoscopic examination via colonoscopy, as well as the abdominal CT examination (with intravenous contrast) did not detect presence of any intra-abdominal tumour.

Intraoperatively, the chronic inflammated diverticulae of the sigmoid were recognized and the sigmoidectomy was performed without complications. After the sigmoid resection, we proceeded with a macroscopic examination of the small bowel. Incidentally, at the distal jejunum, a 2 × 3 cm yellow-white nodule was recognised. 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 and without complications post-operatively, with normal lab values, and was discharged on the fifth post-operative day.

The pathology report of the nodule normal jejunal mucosa confirmed the presence of ectopic pancreatic tissue with glandular acini within the muscularis propria and subserosa of jejunum (Figures 1,2,3).

(×100) Pancreatic acinar tissue in the jejunum wall.

(×25) Pancreatic acinar tissue in the jejunum wall.

(×25) Normal jejunal mucosa with underlying heterotopic pancreatic tissue.

Discussion

The ectopic pancreatic tissue can be present anywhere along the gastrointestinal tract[1,3,4,5,6,7], and in the majority of cases it is located in the submucosa[12,13]. Heterotopic pancreas can be found in all age groups. However, it seems to be more frequent in men than in women[10,14]. Most of the patients with ectopic pancreatic tissue remain asymptomatic and the heterotopic tissue is found incidentally at a histological exam. Nevertheless, there are reports of patients that presented with symptoms like abdominal pain, haematemesis, vomiting, weight loss and intestinal obstruction[12].

Regarding the aetiology of pancreatic heterotopia, two theories exist: the first one suggests that during embryological development, buds of embryonic tissue penetrate into the wall of the growing gut, separating from the main pancreas. The second theory is referring to an inappropriate expression of pluripotent embryonic mesenchymal tissue of the gastrointestinal tract, leading to pancreatic metaplasia[13,15,16]. It is commonly thought that ectopic pancreatic tissue in stomach and duodenum is a derivative of the dorsal pancreatic bud, while that in jejunum and ileum originates from the ventral one[13,16,17,18]. Histologically, most of the tumours are situated in the submucosa, rarely in the muscularis propria, and only seldom (around 13.5%) in the subserosal[12].

In spite of the advances in imaging and other diagnostic tools, a preoperative diagnosis is often difficult[2,16]. Apart from thorough clinical exam, upper GI endoscopy, abdominal ultrasound and/or CT scan may be required to exclude other pathologies with similar features. However, in cases of ectopic pancreatic tissue findings are not specific[13,16,18,19]. A treatment is required only in symptomatic patients, and in most cases it consists of simple surgical resection. The type and extent of the resection depends on the location and the size of the lesion[13,16].

Conclusion

The preoperative diagnosis of an ectopic pancreatic tissue along the gastrointestinal tract may be difficult, due to the non-specific imaging findings. The clinical symptoms, if present, may mimic other pathologies of the gastrointestinal tract. Despite the fact that heterotopia of the pancreas remains rare, it should be considered in the differential diagnosis of unspecific abdominal pain and intramural gastrointestinal obstruction. Considering the intramural location, most of the findings are located in the submucosa (75%), with only 13.5% of them located in the subserosa.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Authors contribution

All authors contributed to conception and design, manuscript preparation, read and approved the final manuscript.

Competing interests

None declared.

Conflict of interests

None declared.

A.M.E

All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.

References

  • 1. Armstrong CP, King PM, Dixon JM, Macleod IB. The clinical significance of heterotopic pancreas in the gastrointestinal tract. Br J Surg 1981 Jun;68(6):384-7.
  • 2. Hsia CY, Wu CW, Lui WY. Heterotopic pancreas: a difficult diagnosis. J Clin Gastroenterol 1999 Mar;28(2):144-7.
  • 3. Elpek GO, Bozova S, Kupesiz GY, Ogus M. An unusual cause of cholecystitis: heterotopic pancreatic tissue in the gallbladder. World J Gastroenterol 2007 Jan 14;13(2):313-5.
  • 4. Inceoglu R, Dosluoglu HH, Kullu S, Ahiskali R, Doslu FA. An unusual cause of hydropic gallbladder and biliary colic-heterotopic pancreatic tissue in the cystic duct: report of a case and review of the literature. Surg Today 1993;23(6):532-4.
  • 5. Weppner JL, Wilson MR, Ricca R, Lucha PA Jr. Heterotopic pancreatic tissue obstructing the gallbladder neck: a case report. JOP 2009 Sep 4;10(5):532-4.
  • 6. Murakami M, Tsutsumi Y. Aberrant pancreatic tissue accompanied by heterotopic gastric mucosa in the gall-bladder. Pathol Int 1999 Jun;49(6):580-2.
  • 7. Terada T, Nakanuma Y, Kakita A. Pathologic observations of intrahepatic peribiliary glands in 1000 consecutive autopsy livers. Heterotopic pancreas in the liver. Gastroenterology 1990 May;98(5 Pt 1):1333-7.
  • 8. Barrocas A, Fontenelle LJ, Williams MJ. Gastric heterotopic pancreas: a case report and review of literature. Am Surg 1973;39361-5.
  • 9. Dolan RV, ReMine WH, Dockerty MB. The fate of heterotopic pancreatic tissue. A study of 212 cases. Arch Surg 1974 Dec;109(6):762-5.
  • 10. Beltran MA, Barria C. Heterotopic pancreas in the gallbladder: the importance of an uncommon condition. Pancreas 2007 May;34(4):488-91.
  • 11. Bromberg SH, Camilo Neto C, Borges AF, Franco MI, Franca LC, Yamaguchi N. Pancreatic heterotopias: clinicopathological analysis of 18 patients. Rev Col Bras Cir 2010 Dec;37(6):413-9.
  • 12. Lai EC, Tompkins RK. Heterotopic pancreas. Review of a 26 year experience. Am J Surg 1986 Jun;151(6):667-700.
  • 13. Hlavaty T, Lukac L, Vyskocil M, Galbavy S. Heterotopic pancreas in gastric antrum with macroscopic appearance of gastric polyp. Bratisl Lek Listy 2002;103(3):117-20.
  • 14. Neupert G, Appel P, Braun S, Tonus C. [Heterotopic pancreas in the gallbladder. Diagnosis, therapy, and course of a rare developmental anomaly of the pancreas]. Chirurg 2007 Mar;78(3):261-4.
  • 15. Makhlouf HR, Almeida JL, Sobin LH. Carcinoma in jejunal pancreatic heterotopia. Arch Pathol Lab Med 1999 Aug;123(8):707-11.
  • 16. Shetty A, Paramesh AS, Dwivedi A, Shetty A, O’ Malley B, Lakra Y. Symptomatic ectopic pancreas. Clin Rev 2002;58203-7.
  • 17. 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 May;82527-42.
  • 18. Jovanovic I, Knezevic S, Micev M, Krstic M. EUS mini probes in diagnosis of cystic dystrophy of duodenal wall in heterotopic pancreas: a case report. World J Gastroenterol 2004 Sep 1;10(17):2609-12.
  • 19. Thoeni RF, Gedgaudas RK. Ectopic pancreas: usual and unusual features. Gastrointest Radiol 1980;537-42.
Licensee to OAPL (UK) 2013. Creative Commons Attribution License (CC-BY)
Keywords