Gastric Outlet Obstruction: The Role of H. pylori Infection Concomitant with Ectopic Pancreatic Tissue

To the Editors

In issue 6 of the European Journal of Pediatric Surgery published in December 2003, Ormarsson et al. reported a nine-year-old boy with gastric outlet obstruction, caused by ectopic pancreatic tissue in the stomach [[3]]. Although ectopic pancreas is usually an incidental finding in adults, it may be associated with intussusception or obstruction during childhood [[1], [2], [4]].

Recently, a teen-aged girl was admitted to our clinic with severe vomiting lasting for the last few months, and she had lost 3 kg weight during this period. She also described epigastric pain and pyrosis. Since severe vomiting and loss of weight were the presenting symptoms, the passage of the upper gastrointestinal tract was studied by barium meal and a partial obstruction at the level of the first part of the duodenum was found. An upper gastrointestinal endoscopy revealed a crater like lesion in the prepyloric area of the greater curvature with antral nodularity (Fig. [1]). It was not possible to advance the endoscope through the pyloric canal because of the presence of severe edema around the pylorus. The histological examination of the antral biopsies revealed severe degree of chronic gastritis associated with Helicobacter pylori (H. pylori). She was given four weeks of treatment of amoxicillin, clarithromycin and proton pump inhibitor combination. Her clinical course was not changed after the eradication of H. pylori, and the second endoscopy was carried out for balloon dilatation of the pyloric canal. It was found that gastritis had improved after the eradication treatment. Dilatation by a pyloric balloon was successful and the endoscope passed through the pyloric canal. Deformed appearance of the first part of the duodenum made us assume the presence of a healed duodenal ulcer or severe duodenal inflammation beforehand.

Fig. 1 Endoscopic appearance of ectopic pancreatic tissue and edematous pylorus of the patient.

After the dilation procedure, she was not able to tolerate feeding and severe vomiting episodes caused fluid and electrolyte imbalance, hence she underwent a laparotomy. It was found that the pyloric canal was circumferentially inflamed and thick. The dissection of the pyloric canal revealed nodular formations, which were 10 - 15 mm in diameter. One of them was located in the prepyloric antrum and pyloric canal, and the other one was located in the first part of the duodenum. Both of them were resected and the operation was completed by pyloroplasty (Heinke Mikulicz). The histopathological examination of the lesions revealed heterotropic pancreatic tissue. After the operation, vomiting episodes ceased and she gained 9 kg weight during four months of follow-up.

She was an interesting patient presenting with gastric outlet obstruction, which might be initiated by H. pylori induced inflammation of the antrum and H. pylori related duodenitis or ulcer within the first part of the duodenum. But H. pylori infection of the stomach per se could not explain the gastric outlet obstruction in this patient because neither the eradication of H. pylori nor the balloon dilatation of pyloric canal resolved the severe vomiting episodes. Although ectopic pancreatic tissue is asymptomatic during childhood, the presence of gastric inflammation concomitant with the ectopic pancreas in antrum might lead to gastric outlet obstruction. Hence, histological presence of severe H. pylori gastritis led us to think that H. pylori induced inflammation, in the presence of ectopic pancreatic tissues around the prepyloric antrum and pyloric canal, could be the reason of gastric outlet obstruction in this patient.

Gastric ectopic pancreas is a rare finding in childhood and the treatment of incidental endoscopic finding of it may be controversial. However, the presence of ectopic pancreatic tissue should be kept in mind in differential diagnosis of unusual cases of gastric outlet obstruction and the treatment should be established individually.

References

• 1 Hamada Y, Yonekura Y, Tanano A, Takada K, Kato Y, Sato M. et al . Isolated heterotopic pancreas causing intussusception.  Eur J Pediatr Surg. 2000;  10 197-200
• 2 Hsia C Y, Wu C W, Lui W Y. Heterotopic pancreas: difficult diagnosis.  J Clin Gastroenterol. 1999;  28 144-147
• 3 Ormarsson O T, Haugen S E, Juul I. Gastric outlet obstruction caused by heterotopic pancreas.  Eur J Pediatr Surg. 2003;  13 410-413
• 4 Steyaert H, Voigt J J, Brouet P, Vaysse P. Uncommon complication of gastric duplication in a three-year-old child.  Eur J Pediatr Surg. 1997;  7 243-244