310 J La state Med soc VoL 162 november/December 2010
Journal of the Louisiana State Medical Society
clinical case oF the month
Maneesh K. Gupta, MD; Jordan J. Karlitz, MD; Daniel L. Raines, MD;
Sander S. florman, MD; and fred A. Lopez, MD (Section Editor)
Heterotopic pancreas (HP) is typically an asymptomatic
malformation that can present anywhere along the
gastrointestinal tract. It is often found incidentally as a
single focal mass in patients with abdominal complaints
undergoing routine diagnostic testing. HP occasionally
presents symptomatically, and the manifestations vary
depending on the location of the lesion. We describe the first
reported case of symptomatic jejunal HP which presents as
a circumferential infiltrative lesion with multiple foci rather
than a single focal mass. This is accompanied by a review
of the current literature regarding the pathogenesis, clinical
manifestations, and treatment of HP.
A 37-year-old woman with a history of systemic lupus
erythematosus and cadaveric kidney transplant in 1997 was
referred to our institution for recurrent nausea, vomiting,
diarrhea, and abdominal pain of two years duration. Her
symptoms occurred in discrete episodes requiring repeated
hospitalizations for dehydration and abdominal pain. On
physical exam, her abdomen was tender to palpation in
the left upper quadrant and epigastrum, with voluntary
guarding but no rebound tenderness.
Extensive evaluation including laboratory studies,
abdominal ultrasound, upper endoscopy, and colonoscopy
were unrevealing. An abdominal computed tomographic
(CT) scan with oral and intravenous contrast demonstrated
an area of abnormal small bowel localized to the
proximal jejunum (Figure 1). Capsule endoscopy was
subsequently performed to evaluate the small bowel and
was unremarkable. Due to persistent symptoms, the patient
underwent single bowel enteroscopy (SBE) to visualize
directly and to biopsy the abnormal jejunal segment seen
Examination by SBE revealed a 6cm grossly edematous
and circumferentially ulcerated segment of mucosa located
approximately 100cm distal to the Ligament of Treitz
(Figure 2). The lesion was biopsied; however, pathological
examination only revealed mild vascular congestion.
The patient was eventually taken for surgical resection.
Intraoperatively, the lesion was visualized. In addition,
a separate ulcerated lesion was seen in the small bowel
10cm proximal to the original lesion. Both lesions were
resected, and histological examination revealed heterotopic
pancreatic tissue involving the adventitia, muscularis
propria, and submucosa extending to the muscularis
mucosa (Figure 3). There was no evidence of vasculitis.
The patient experienced symptoms of abdominal pain
and nausea postoperatively but these symptoms resolved
completely within one month.
figure 1. Axial computed tomographic image of the abdomen
demonstrating gross thickening of a jejunal segment (arrows).