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DOI: 10.1055/s-0034-1365445
Jejunal ectopic pancreas: a rare cause of gastrointestinal bleeding diagnosed using balloon enteroscopy
Publication History
Publication Date:
19 November 2014 (online)
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A 42-year-old man with arterial hypertension and human immunodeficiency virus (HIV) infection was admitted for investigation of melena. Blood tests revealed iron deficiency anemia (hemoglobin concentration was 4.9 g/dL). On further questioning, the patient acknowledged having experienced several months of intermittent melena and recurrent episodes of abdominal pain. He denied weight loss or other gastrointestinal symptoms. Esophagogastroduodenoscopy and colonoscopy failed to identify a source of bleeding. To complete the evaluation, video capsule endoscopy was performed, which disclosed a subepithelial tumor located in the jejunum ([Fig. 1]), without other relevant findings in the small bowel. Subsequent single-balloon enteroscopy (SIF-Q180; Olympus Medical Systems, Tokyo, Japan) was carried out through the oral insertion route. A 20-mm caterpillar-like subepithelial tumor was observed within the topography of the lesion previously described ([Video 1]), with a smooth surface and focal erythema in the mucosa ([Fig. 2]). Endoscopic tattooing was performed and the patient was referred for surgical resection. Pathologic examination revealed pancreatic acinar cells, prominent secretory ducts, and islet cells in the jejunal submucosa ([Fig. 3]), consistent with ectopic pancreas (type I, Heinrich’s classification). At 6-month follow-up, the patient remains asymptomatic.
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The term “ectopic pancreas” refers to pancreatic tissue that lacks anatomic and vascular connections with the parent organ [1]. Jejunal ectopic pancreas is a rare entity; it is usually asymptomatic and diagnosed incidentally by imaging. Very occasionally, it may become clinically evident when complicated by inflammation, obstruction, or bleeding, with melena and/or anemia [2], as in the present case. The enteroscopic findings have rarely been described.
We report an unusual case of obscure gastrointestinal bleeding with severe anemia due to a jejunal ectopic pancreas, detected by video capsule endoscopy and single-balloon enteroscopy. It appeared caterpillar-like on endoscopy, which has been suggested by Takeda et al. [3] and Tsurumaru et al. [4] to be characteristic of small-bowel ectopic pancreas. The differential diagnosis against other small-bowel subepithelial tumors is usually difficult [5]. Resection is the suggested treatment for complicated cases.
Endoscopy_UCTN_Code_CCL_1AC_2AH
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References
- 1 Dolan RV, ReMine WH, Dockerty MB et al. The fate of heterotopic pancreatic tissue: a study of 212 cases. Arch Surg 1974; 109: 762-765
- 2 Fikatas P, Sauer IM, Mogl M et al. Heterotopic ileal pancreas with lipoma and coexisting fibromatosis associated with a rare case of gastrointestinal bleeding. A case report and review of the literature. JOP 2008; 9: 640-643
- 3 Takeda Y, Nakase H, Chiba T. Ectopic pancreas at the jejunum. Dig Liver Dis 2011; 43: e6
- 4 Tsurumaru D, Utsunomiya T, Kayashima K et al. Heterotopic pancreas of the jejunum diagnosed by double-balloon enteroscopy. Gastrointest Endosc 2007; 66: 1026-1027
- 5 Rana SS, Bhasin DK, Nada R et al. Heterotopic pancreas in the jejunum presenting as a submucosal lesion on endoscopy. JOP 2009; 10: 419-420