Ectopic pancreas is a relatively rare submucosal tumor
(SMT) of gastrointestinal (GI) tract, and it is histologically si-
milar to normal pancreas. It may occur at a variety of sites in
the GI tract with a propensity to affect the stomach and small
intestine. Although it is usually a silent anomaly, an ectopic
pancreas may become clinically evident when complicated by
inflammation, bleeding, obstruction or malignant transfor-
mation.1,2 Although several cases of ectopic pancreas accom-
panied by bleeding have been reported,3,4 bleeding found by cap-
sule endoscopy has not been reported except one in Taiwan.5
Here, we report a case of an ectopic pancreas in a 46-year-old
woman, who visited our hospital with a sign of GI bleeding.
The capsule endoscopy revealed that the bleeding was caused
by the SMT in the small intestine, and it was surgically re-
Clin Endosc 2012;45:194-197
194 Copyright © 2012 Korean Society of Gastrointestinal Endoscopy
A 46-year-old female presented with episodes of melena
and hematochezia accompanied by dizziness, which had been
continuing for a week. The patient had been on antihyperten-
sive medication including aspirin for 2 years at the moment.
The vital signs showed that pulse rate was 90/min, blood pres-
sure 100/60 mm Hg, and respiratory rate 20/min. She com-
plained mild periumbilical discomfort, but no tenderness was
observed. Her initial serum hemoglobin and hematocrit levels
were 4.7 g/dL and 14.4%, respectively, and there were no ab-
normal findings in biochemical and blood coagulation tests.
A nasogastric tube was inserted and irrigation with saline was
performed. The irrigated saline was clear without blood. On
rectal examination, dark red liquid stool was noted. Abdomi-
nal computed tomography scan showed no significant abnor-
malities. Upper GI endoscopy was performed, and there were
no lesions to cause bleeding at the esophagus, stomach, or du-
odenum. On the 2nd hospital day, we performed colonosco-
py, which also showed no specific bleeding lesion. Following
colonoscopy, second-look upper GI endoscopy was perform-
ed, which did not reveal the bleeding focus. Then, a capsule
endoscopy was performed subsequently to evaluate the ob-
scure GI bleeding. It revealed active bleeding from a submuco-
sal lesion slightly larger than 1 cm located in the jejunum (Fig. 1)
without other erosions or erythemas in the small bowel ex-
Ectopic Pancreas Bleeding in the Jejunum Revealed
by Capsule Endoscopy
Mi-Jeong Lee1, Jae Hyuck Chang1, Il Ho Maeng1, Jin Young Park1,
Yun Sun Im1, Tae Ho Kim1, Sok-Won Han1 and Do Sang Lee2
Departments of 1Internal Medicine and 2Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea
Ectopic pancreas is defined as pancreatic tissue found outside the usual anatomic location. It is often found incidentally at different sites
in the gastrointestinal (GI) tract. The incidence of ectopic pancreatic tissue in autopsy series is 1% to 2%, with 70% of the ectopic lesions
found in the stomach, duodenum and jejunum. Although it is usually a silent anomaly, an ectopic pancreas may become clinically evi-
dent when complicated by inflammation, bleeding, obstruction or malignant transformation. We report a case of ectopic pancreas locat-
ed in the jejunum and presenting as an obscure GI bleeding, which was diagnosed by capsule endoscopy.
Key Words: Capsule endoscopy; Gastrointestinal hemorrhage; Ectopic pancreas
Received: August 20, 2011 Revised: January 31, 2012
Accepted: February 3, 2012
Correspondence: Jae Hyuck Chang
Department of Internal Medicine, Bucheon St. Mary’s Hospital, The Catholic
University of Korea College of Medicine, 327 Sosa-ro 327 beon-gil, Wonmi-
gu, Bucheon 420-717, Korea
Tel: +82-32-340-2227, Fax: +82-32-340-2255, E-mail: firstname.lastname@example.org
cc This is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License (http://creativecommons.org/
licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution,
and reproduction in any medium, provided the original work is properly cited.
Print ISSN 2234-2400 / On-line ISSN 2234-2443
Lee MJ et al.
cept the lesion.
On the 3rd hospital day, barium small bowel examination
was performed for exact localization of the tumor, but it could
not clarify the SMT of the small bowel. Finally, the patient un-
derwent surgery. The SMT was located in the distal jejunum.
It was a round, well-demarcated solid mass (1.5×1.5 cm) with
a yellow rubbery surface and umbilication (Fig. 2). Histologi-
cal examination revealed submucosal ectopic pancreatic tis-
sues with focal mucosal defect on the surface (Fig. 3). The pa-
tient recovered well after the surgery and has been followed
up on an outpatient bases.
Ectopic pancreas is a disease showing histological structures
similar to normal pancreatic tissues without any anatomical re-
lation or direct connections by blood vessel with the pancreas.
It was first reported in 1727 by Schiltz, and its histological fea-
tures were studied in 1859 by Klob et al.6 Most cases of ecto-
pic pancreas are found by radiological screenings, endoscopic
examinations or during surgeries or autopsies.6,7 Because ec-
topic pancreas is shown as a SMT by endoscopy, differential
diagnosis is necessary to distinguish from other SMTs arising
from GI tract. However, pathological diagnosis of ectopic pan-
creas by endoscopy-guided biopsy is often difficult because
the tumor is located deeper than where the biopsy forceps can
reach. Recently, endoscopic ultrasonographic biopsies are in-
troduced for diagnosis of SMTs.8 Because aspirated biopsy
Fig. 1. Capsule endoscopic findings. Capsule endoscopy reveals
a submucosal lesion, with active bleeding from central umbilicat-
ed surface located in the jejunum.
Fig. 2. Gross findings of the resected specimen. (A) A 1.5×1.5 cm submucosal tumor with yellow and rubbery mucosal surface. (B) Erosion
or umbilication is seen on the surface of tumor.
Fig. 3. Microscopic findings of the resected specimen. (A, B) Histologic examination of the resected specimen revealed exocrine tissue of the
pancreas with acinus structures and secretory ducts seen in the submucosa (A, H&E stain, ×40; B, H&E stain, ×100). (C) Focal mucosal de-
fect (2 mm) is seen on the surface of tumor (H&E stain, ×40).
A B C
196 Clin Endosc 2012;45:194-197
Ectopic Pancreas Bleeding Revealed by Capsule Endoscopy
specimen is often not enough for the diagnosis and the cost of
the procedure is high, surgical resection is often considered and
performed. Around 70% of ectopic pancreas cases are found
in the stomach (24% to 38%), duodenum (9% to 36%), and je-
junum (0.5% to 27%). Ectopic pancreas has been also report-
ed in the colon, spleen, liver, Meckel’s diverticulum, gallblad-
der, bile ducts, or fallopian tubes.9 Ectopic pancreas in the
small intestine mostly occurs in the duodenum and jejunum.
The second portion of the duodenum around the ampulla of
Vater is considered as a frequent site of ectopic pancreas,10 whi-
ch is rare in the ileum, though.11 Most cases of ectopic pancre-
as are known to be asymptomatic,3 but some cases might ac-
company symptoms.11 The most common symptoms include
epigastric pain (77%), abdominal fullness (30%), and hema-
tochezia (24%).6 Bleeding has been reported in 3 out of 73
symptomatic cases among 212 ectopic pancreas patients,4 and
in 5 out of 15 symptomatic cases among 39 ectopic pancreas
The patient in this case report took aspirin, which made it
difficult to identify the causes of bleeding in the ectopic pan-
creas. There were no other erosion by aspirin in the small bo-
wel, and consequently we considered that the aspirin was not
the major factor for bleeding. However, aspirin could have in-
cidentally induced ulcer in the ectopic pancreas, which could
be a trigger factor for bleeding in the ectopic pancreas of small
It is difficult to identify bleeding from ectopic pancreas in
the small intestine and it is often considered as obscure GI
bleeding. Obscure GI bleeding is known to occupy about 5%
of all GI bleedings, and 75% of these are thought to be a bleed-
ing from a lesion of the small bowel.13 For the evaluation of the
small bowel, capsule endoscopy, push enteroscopy, double bal-
loon enteroscopy, angiography, and barium small bowel ex-
amination are available.13,14 A retrospective study reported that
3 cases of ectopic pancreas causing bleeding in the small bowel
among 76 cases of obscure GI bleeding were identified using an-
giography, barium small bowel examination, and enteroscopy.7
There were reports of an ectopic pancreas in the duodenum ac-
companying massive bleeding detected by side-viewing en-
doscope followed by surgical resection,15 and a jejunal ectopic
pancreas with massive bleeding detected by red blood cell scan
and angiography.16 Ectopic pancreas bleeding detected by
double balloon endoscopy was also reported.17
Capsule endoscopy has high sensitivity and specificity in
detecting cases of obscure GI bleeding.18 A retrospective mul-
ticenter study has reported that capsule endoscopy discovered
the causes of obscure GI bleedings in 56.2% of 151 patients.19
It is a better result compared with barium small bowel exam-
ination, angiography, or push enteroscopy.20 Bleeding from
SMT was also well identified in our case by capsule endoscopy.
Capsule endoscopy can be considered as the first evaluation
method for small bowel lesions, especially those with bleeding
from SMT. Ectopic pancreas bleeding was detected by cap-
sule endoscopy only in one case in Taiwan as far as we know,5
and there have been no reports of it in Korea. We reported
here a case of bleeding from jejunal ectopic pancreas, which
was revealed by capsule endoscopy and treated by surgical
Conflicts of Interest
The authors have no financial conflicts of interest.
The author thanks Dr. Jin A Kim for preparing the pathologic specimens
for Fig. 3A-C and taking the photomicrographs.
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