Heterotopic pancreatic tissue in gall bladder incidentally detected in a case of acute cholecystitis: A case report and review of the literature

Heterotopic pancreatic tissue in the gall bladder is a very uncommon lesion. In most cases, it is an incidental finding. The placement of pancreatic tissue in an organ outside the pancreas is called pancreatic heterotopy. Heterotopic pancreas is commonly found in the stomach, small intestine, and Meckel’s diverticulum. It has rarely been seen in the gall bladder, bile duct, splenic hilum, or liver. We present a case of incidentally discovered heterotopic pancreatic tissue in a case of acute cholecystitis in a 63-years-old lady having a history of pain in the right hypochondriac region

Coristoma pancreático dentro de un divertículo duodenal: a propósito de un caso / Pancreatic Choristoma within a duodenal diverticulum, an accidental finding: apropos of a case

Resumen El coristoma pancreático, o páncreas heterotópico, es una condición rara en gastroenterología. Esta entidad consiste en el hallazgo de tejido pancreático aberrante, en alguna zona del tracto gastrointestinal, sin continuidad vascular o anatómica con el páncreas normal, es poco reportado y presenta sintomatología variable. Presentamos el caso de un individuo de 46 años con dolor abdominal a quien se le encontró mediante exámenes invasivos un divertículo duodenal, el cual al examen histopatológico e inmunohistoquímico mostró un coristoma pancreático.

Abstract Pancreatic choristoma, also called heterotopic pancreas is a rare condition in gastroenterology. This entity consists of the presence of aberrant pancreatic tissue in some other area of the gastrointestinal tract without vascular or anatomical continuity with the normal pancreas; it has been seldomly reported and it could exhibit variable symptomathology. We herein report the case of a 46-year-old male, who presented with abdominal pain and was found, through invasive examinations to have a pancreatic choristoma within a duodenal diverticulum. The diagnosis was made using histopathology and immune-histochemistry testing.

Heterotopia pancreática en pólipo gástrico. Presentación de caso / A case of heterotopic pancreas in a gastric polyp

Resumen La heterotopia pancreática es un hallazgo poco frecuente, en ocasiones accidental, que se puede observar en cualquier nivel del tracto digestivo e inclusive fuera del mismo; es congénita y su patogenia está en discusión. Aunque su forma de presentación es lenta y progresiva y su comportamiento benigno y asintomático, en ocasiones puede originar manifestaciones obstructivas, hemorrágicas, inflamatorias y neoplásicas. En este último caso es imprescindible el diagnóstico histopatológico. Se presenta el caso de un paciente sintomático con heterotopia pancreática a nivel del píloro gástrico cuya localización es bastante infrecuente.

Abstract Pancreatic heterotopia is rare and is sometimes found accidentally. It can occur anywhere in the digestive tract and even outside of it. Heterotopic pancreas is congenital, but its pathogenesis is under discussion. Although it develops slowly and progressively, its behavior is benign and asymptomatic. Nevertheless, it can manifest in obstructions, hemorrhaging, inflammation and neoplasia. In the latter case, histopathological diagnosis is essential. We present the case of a symptomatic patient with pancreatic heterotopia at the gastric pylorus, a very uncommon location.

A Rare Case of Early Gastric Cancer Combined with Underlying Heterotopic Pancreas

Heterotopic pancreas in the stomach is usually asymptomatic and benign. Here, we presented a rare case of an early gastric cancer overlying a heterotopic pancreas. A 48-year-old woman underwent esophagogastroduodenoscopy, which revealed a subepithelial mass measuring 2.0×1.5 cm on the gastric antrum with a 1-cm erosive erythematous discoloration on the surface. A biopsy specimen showed moderately differentiated tubular adenocarcinoma. Endosonography showed a heterogeneous hypoechoic mass measuring 1.3×0.6 cm, with indistinct margins in the second and third layers of the gastric wall; anechoic tubular structures within the mass were suggestive of heterotopic pancreas. Distal gastrectomy was performed, which confirmed an early gastric cancer confined to the mucosa, and a separate underlying heterotopic pancreas. Although heterotopic pancreas is most likely benign, careful endoscopic observation of the mucosal surface is necessary to avoid overlooking a coincident early gastric cancer.

Characteristics of clinicopathology and immunohistochemical molecular markers of 92 cases of heterotopic pancreas in upper gastrointestinal tract / 中华消化杂志

Objective To investigate the clinicopathological characteristics and the expression of related molecular markers of heterotopic pancreas for better understanding and avoiding overtreatment of this disease.Methods From 24th March 2009 to 10th November 2016,92 patients with heterotopic pancreas in upper digestive tract diagnosed after endoscopic submucosal dissection(ESD),were collected. Tissues were sectioned and pathologically classified by Heinrich classification.The expressions of seven different molecular markers including cytokeratin(CK)19,insulin,trypsin,Ki-67,p53,CD133 and CD56 were detected by immunohistochemistry staining. Clinical features, pathological features and immunohistochemical results were retrospectively analyzed.Analysis of variance and Kruskal-Wallis test were used.Results According to Heinrich classification,the percentages of type Ⅰ,Ⅱ,and Ⅲ of heterotopic pancreas were 27.2%(25/92),63.0%(58/92)and 9.8%(9/92),respectively.There was no type Ⅳ patients.The heterotopic pancreas mainly located in stomach with proportion being about 91.3%(84/92)of the total heterotopic pancreas.CK19(the marker of pancreas ducts),insulin(as marker of endocrine function)and trypsin(as the marker of exocrine function)were all expressed in heterotopic pancreas.The positive rate of CD56,a pancreatic neuroendocrine marker,was 66.3%(61/92).The umbilicus like depression was the typical endoscopic appearance of heterotopic pancreas,which only found in 29 patients(31.5%).The average rate of Ki-67,cell proliferation index,was(2.08 ± 1.41)%.The expression of mutant p53 was negative in all 92 cases of heterotopic pancreas.The average staining area of CD133,a marker of pancreatic cancer stem cell,was(2.53 ± 2.43)%.The average follow-up period of 92 patients was(43.6 ± 27.5)months.No relapse and malignant change were found and all patients survived after ESD.Conclusions Heterotopic pancreas has normal pancreatic construction and function.The cell proliferation index is low in heterotopic pancreas and no mutant p53 expression is found.The expression of CD133 is also low.Heterotopic pancreas is a congenital benign disease which requires a long-term follow-up rather than overtreatment.

Application of clip traction to endoscopic submucosal dissection for heterotopic pancreas in stomach / 中华消化内镜杂志

Objective To evaluate the efficacy and safety of clip traction in endoscopic submucosal dissection (ESD) for heterotopic pancreas in stomach.Methods Data of 62 patients with pathologically confirmed heterotopic pancreas treated by ESD between May 2013 and February 2016 were retrospectively studied in Department of Gastroenterology of Xinqiao Hospital,whose lesions were single and origins were submucosal.Thirty-six cases underwent ESD with clip traction (clip group,n=36),and 26 cases underwent ESD without clip traction (non-clip group,n =26).The procedure time,visualization of the submucosal during dissection,complications and the result of follow-up were evaluated between the two groups.Results ESD was successful in all cases.The procedure time was significantly shorter in the clip group than in the non-clip group (19.35±10.34 min VS 27.02± 14.27 min,t'=2.333,P=0.023),and good visualization was obtained by applying clip traction.The rate of bleeding in the clip group was 55.6％ (20/36),and that in the non-clip group was 61.5％ (16/26).There was no significant difference between the two groups(x2 =0.222,P =0.638).Moreover,perforation did not occur in the clip group,but occurred in one patient in the non-clip group (3.8％,1/26).There was no significant difference between the two groups (P =0.419).All patients were followed up,there was no recurrence.Conclusion ESD is effective and safe for heterotopic pancreas in stomach.Clip traction can shorten the operation time and reduce complications of ESD.

Clinical observation of endoscopic submucosal dissection for uppergastrointestinal ectopic pancreas (36 cases) / 中国内镜杂志

Objective To evaluate the feasibility, efficacy, and safty of endoscopic submucosal dissection (ESD) in treatment of uppergastrointestinal ectopic pancreas. Methods 36 uppergastrointestinal ectopic pancreas were treated with ESD from January 1 2012 to November 30 2014. The definitive histological diagnosis of ectopic pancreas was made after the endoscopic treatment. We analyzed the operation method, dissected tissue, complication, retrospec-tively. Results 34 cases were located in stomach, the other 2 in duodenum. All cases underwent ESD, the mean op-erating time was 66 min. The mean dissected tissue diameter was 21 mm × 16 mm in the 36 cases. The curative re-section rate was 100.00 %. Bleeding rate of ESD was 2.77 %(1/36). Perferation rate of ESD was 2.77 %(1/36). 2 cases suffered from low grade fever. None need surgical intervention. Recurrence rate was 0.00%. Conclusions ESD is a minimally invasive technique that allows resection of whole lesions and provides precise histological information, which is particularly suitable for uppergastrointestinal ectopic pancreas.

Simultaneous Manifestation of Gangliocytic Paraganglioma and Heterotopic Pancreas of Ampulla of Vater Treated by Endoscopic Resection / 대한췌담도학회지

Gangliocytic paraganglioma is an uncommon tumor of digestive system that is usually found in the second portion of duodenum. It is generally considered benign tumor, although few reports of local recurrences and regional lymph node metastases have been made. Gangliocytic paraganglioma is characterized by its histologic pattern including ganglion cells, spindle cells and epithelioid cells. Heterotopic pancreas, also known as ectopic pancreas, is a pancreatic tissue appeared outside of its normal location lacking anatomic or vascular connection with the pancreas. In duodenum, it is a relatively unusual lesion that may be found incidentally during surgery or endoscopy. We present a case of 39-year-old woman with gangliocytic paraganglioma combined with heterotopic pancreas in the ampulla of Vater successfully treated by endoscopic resection.

Simultaneous Manifestation of Gangliocytic Paraganglioma and Heterotopic Pancreas of Ampulla of Vater Treated by Endoscopic Resection / 대한췌담도학회지

Gangliocytic paraganglioma is an uncommon tumor of digestive system that is usually found in the second portion of duodenum. It is generally considered benign tumor, although few reports of local recurrences and regional lymph node metastases have been made. Gangliocytic paraganglioma is characterized by its histologic pattern including ganglion cells, spindle cells and epithelioid cells. Heterotopic pancreas, also known as ectopic pancreas, is a pancreatic tissue appeared outside of its normal location lacking anatomic or vascular connection with the pancreas. In duodenum, it is a relatively unusual lesion that may be found incidentally during surgery or endoscopy. We present a case of 39-year-old woman with gangliocytic paraganglioma combined with heterotopic pancreas in the ampulla of Vater successfully treated by endoscopic resection.

Diagnosis and treatment of heterotopic pancreas at the angular notch of stomach misdiagnosed as gastric stromal tumor / 中华消化外科杂志

Heterotopic pancreas is usually defined as a presence of pancreatic tissue without any anatomical or vascular continuity,and is one of the congenital and rare diseases.The clinical manifestations are easily confused with other gastrointestinal diseases,and conventional endoscopic examination cannot provide a clear preoperative diagnosis,therefore heterotopic pancreas is often misdiagnosed.It is very important to distinguish heterotopic pancreas and other digestive diseases.In this article,the clinical characteristics,differential diagnosis and treatment method of one patient with heterotopic pancreas who was admitted to the Affiliated Hospital of Chengde Medical College in March 2014 were analyzed.

Heterotopic Pancreas Presented as Duodenal Tumor with Obstruction / 대한소아소화기영양학회지

Heterotopic pancreas (HP) is defined as pancreatic tissue lacking anatomic and vascular continuity with the main body of the pancreas. Most are asymptomatic, but can cause ulcer, bleeding, intussusception, and mechanical obstruction. Herein, we presented one case of HP presented as duodenal tumor causing duodenal obstruction. A 7-year-old girl visited the emergency room for abdominal pain with vomiting for 24 hours. Computed tomography and upper gastrointestinal series revealed a polypoid mass with short stalk in the 2nd portion of duodenum. We attempted an endoscopic removal. However, the lumen was nearly obstructed by the mass and the stalk was too broad and hard to excise. The mass was surgically removed via duodenotomy. It was confirmed as a HP with ductal and acini components (type 2 by Heinrich classification). Postoperatively, the patient has been well without any complication and recurrence.

Adenocarcinoma Arising from Heterotopic Pancreas in Association with a Splenic Cyst.

We report a rare case of adenocarcinoma arising from heterotopic pancreas in splenectomy specimen operated for a Splenic Cyst. This 40 year old female patient presented with vague upper abdominal pain and swelling. USG showed a large cyst within the spleen. The cyst along with the spleen is removed after laparotomy. The pancreas and other abdominal organs were unremarkable on ultrasonography and intraoperative examination. Gross examination showed a cyst with a smooth lining, entirely within the spleen. A small locule, communicating with the main cyst showed small papillary projections. On light microscopy, the cyst wall is lined by single layer of columnar cells. Section from papillary areas showed histological appearance of papillary adenocarcinoma. Remnant of normal pancreatic tissue was discovered at the wall of the cyst. We presume an origin from heterotopic pancreatic tissue in the spleen for this neoplasm and reporting the case for its rarity.

Heterotopic pancreas of the gallbladder associated with segmental adenomyomatosis of the gallbladder / 대한외과학회지

Heterotopic pancreas in the gallbladder is extremely rare and usually incidentally discovered at the pathologic examination followed by cholecystectomy for symptomatic gallbladder disease. Up to the presents, only about 30 cases have been reported. We report the case of a 36-year-old female who presented with symptoms of cholecystitis. The histological analysis followed by cholecystectomy revealed heterotopic pancreas of the cystic duct.

Heterotopic Pancreas of the Jejunum Identified by Capsule Endoscopy / 대한소화기내시경학회지

Heterotopic pancreas is an uncommon condition that commonly occurs in the gastrointestinal tract such as the stomach and small bowel. It is defined as the presence of pancreatic tissue outside its usual location and lacking anatomical and vascular continuity with the pancreas. A heterotopic pancreas is usually found incidentally and is mostly silent; however, it rarely causes abdominal pain, weight loss, bleeding, or ileus. A 49-year-old male presented with intermittent abdominal pain for 4 weeks. We report a case with submucosal features of a jejunal heterotopic pancreas with the aid of capsule endoscopy and a histological confirmation through a single port laparoscopic segmental jejunectomy.

A Case of Heterotopic Pancreas within Meckel's Diverticulum with Obscure Gastrointestinal Bleeding / 대한내과학회지

Heterotopic pancreas is a tissue histologically similar to normal pancreatic tissue found in a location other than the usual place, and having no anatomic or vascular connection with the pancreas itself. Heterotopic pancreas is usually asymptomatic and found incidentally. However, it can cause problems such as abdominal pain, melena, anemia, and severe bleeding. We report a case of a 29-year-old woman with obscure gastrointestinal bleeding caused by heterotopic pancreas located in Meckel's diverticulum. Gastroduodenoscopy and colonoscopy showed no bleeding focus. By capsule endoscopy and double balloon enteroscopy, a bleeding focus was suspected in the ileum. The patient received a laparoscopic resection of the Meckel's diverticulum. Pathologic examination revealed heterotopic pancreatic tissue within the muscular layer of the diverticulum. The patient recovered well without further bleeding.

Partial gastric outlet obstruction caused by a huge submucosal tumor originating in the heterotopic pancreas

A 21-year-old woman presented gastrointestinal manifestation showing intermittent abdominal pain, nausea, and vomiting. An upper endoscopic examination showed round, elevated mucosa at the antrum of the stomach anterior wall. After CT scanning, a huge degenerated gastrointestinal stromal tumor was suspected. Subtotal gastrectomy with Billroth II anastomosis was performed. Histologically, pseudocystic degeneration of the heterotopic pancreas was confirmed. The patient showed eventful postoperative course except temporary dilated gastric emptying. The patient is doing well without any abnormal symptom at 8-month follow-up. This report is a rare case of gastric outlet obstruction caused by a pseudocyst originating from a heterotopic pancreas in the gastric antrum.

Coristoma pancreático en la vesícula biliar / Heterotopic pancreas found in the gallbladder: report of one case

We report a 54 years old woman presenting with pain in the right upper abdominal quadrant. An abdominal ultrasound showed multiple gallbladder stones. The patient was operated with the diagnosis of cholelithiasis. During the pathological study of the excised gallbladder a 0.9 cm diameter yellowish nodule was found, that corresponded to heterotopic pancreatic tissue.

La heterotopía pancreática corresponde a la presencia de tejido pancreático fuera de su localización habitual, que carece de continuidad anatómica y vascular con el páncreas normal; el 85 por ciento a 90 por ciento de los casos reportados comprometen estómago, duodeno o yeyuno, mientras que la localización en vesícula biliar es infrecuente y corresponde tan sólo al 1 por ciento de ellas. Esta entidad es generalmente asintomática y en la mayoría de los casos su diagnóstico constituye un hallazgo incidental durante el examen anatomo-patológico de la pieza quirúrgica. Se presenta el caso de una mujer de 54 años sometida a colecistectomía abierta electiva con el diagnóstico de colecistolitiasis. El examen anatomo-patológico de la pieza operatoria, junto con diagnosticar la colecistitis crónica litiásica, describe la presencia de tejido pancreático heterotópico en el espesor de la pared y a nivel del cuello de la vesícula biliar compuesto por acinos y conductos pancreáticos.

Coristoma pancreático en la vesícula biliar: Reporte de dos casos / Pancreatic choristoma in the gallbladder: Report of two cases

Pancreatic choristoma is the ocurrence of normal pancreatic tissue in an abnormal location without any anatomic continuity with the main body of the gland. Although heterotopia is uncommon in the gallbladder and biliary tract, anecdotic cases of gastric mucosa, liver, adrenal gland and pancreas among other tissues have been described. We report an eight year-old male and a 22 year-old female, electively operated for symptomatic cholelithiasis. On pathology, a nodule identified as a pancreatic endocrine and exocrine choristoma, was found in the gallbladder wall of both patients. We employed immunohistochemistry to characterize this choristoma. Tubular and epithelial structures were immunoreactive to cytokeratins 7, 8, 18, 19 and 20 and to CA19-9. Exocrine activity was documented by immunoreactivity to al-antitrypsin and al-chemotrypsin. Other immunohistochemical markers such as insulin and somatostatin were positive identifying endocrine activity.

A case of symptomatic heterotopic pancreas with huge pseudocyst formation / 대한내과학회지

Heterotopic pancreas is the presence of pancreatic tissue that lacks anatomic and vascular continuity with the main body of the pancreas. Most patients with heterotopic pancreas are asymptomatic. Any pathologic change in the normal pancreas also can occur in heterotopic pancreas; namely, pancreatitis, cyst formation, hemorrhage, necrosis and neoplastic chang. But pancreatic pseudocyst formation is extremely rare in heterotopic pancreas. Recently, we experienced a case of gastric heterotopic pancreas in a 22-year-old women complicated by chronic pancreatitis with pseudocyst formation. She underwent a antrectomy with Billroth I reconstruction. Symptoms were relieved after operation. Microscopic findings were compatible with gastric heterotopic pancreas with pseudocyst formation. Herein, we report a case of symptomatic heterotopic pancreas with huge pseudocyst formation and the pertinent literatures were reviewed briefly.

Islet Cell Tumor Arising from Heterotopic Pancreas in the Duodenum: A Case Report

It is difficult to distinguish an islet tumor originating from heterotopic pancreas tissue from the other submucosal tumors. Although the malignant transformation of a heterotopic pancreas, including islet cell tumor, is extremely rare, it remains an important consideration in the differential diagnosis of duodenal submucosal masses. We have demonstrated the radiologic appearance and the clinical-pathologic findings of a highlighted, rare case of islet cell tumor arising from a heterotopic pancreas in the duodenal wall.