Pediatr Gastroenterol Hepatol Nutr.  2015 Dec;18(4):280-285. 10.5223/pghn.2015.18.4.280.

Heterotopic Pancreas Presented as Duodenal Tumor with Obstruction

• Kim SH
• Nam SH

• KMID: 2383307
• DOI: http://doi.org/10.5223/pghn.2015.18.4.280

Abstract

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.

Keyword

Duodenal obstruction; Pancreas; Duodenal neoplasms; Heterotopic pancreas

MeSH Terms

Abdominal Pain
Child
Duodenal Neoplasms
Duodenal Obstruction
Duodenum
Emergency Service, Hospital
Female
Hemorrhage
Humans
Intussusception
Pancreas*
Recurrence
Ulcer
Vomiting

Figure

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  Fig. 1 Simple abdomen revealed a 3 cm sized soft tissue density near the pylorus without small bowel obstruction (arrow).

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  Fig. 2 Computed tomography revealed a well demarcated mass near the ampulla of Vater in the 2nd portion of duodenum.

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  Fig. 3 Ultrasonography showed hyperechoic mass-like lesion with short stalk in the 2nd portion of duodenum.

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  Fig. 4 Upper gastrointestinal series revealed ovoid-shaped filling defect in the 2nd portion of duodenum.

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  Fig. 5 After Kocher's maneuver, we identified the mass and exposed it after duodenotomy. We identified the mass (A) and exposed it after duodenotomy (B).

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  Fig. 6 Under the microscope, nodular lesions were composed of variably dilated ductular mucinous and pancreatic exocrine acinar tissue (H&E; A: ×40, B: ×200). Acini tissue showed positive reaction to CK19 immunohistochemistry (C: ×40, D: ×200). It was confirmed as heterotopic pancreas, ductal and acini component (type 2 by Heinrich classification).

Reference

1. Lai EC, Tompkins RK. Heterotopic pancreas. Review of a 26 year experience. Am J Surg. 1986; 151:697–700.

2. Tolentino LF, Lee H, Maung T, Stabile BE, Li K, French SW. Islet cell tumor arising from a heterotopic pancreas in the duodenal wall with ulceration. Exp Mol Pathol. 2004; 76:51–56.

3. Jiang LX, Xu J, Wang XW, Zhou FR, Gao W, Yu GH, et al. Gastric outlet obstruction caused by heterotopic pancreas: a case report and a quick review. World J Gastroenterol. 2008; 14:6757–6759.

4. De Castro Barbosa JJ, Dockerty MB, Waugh JM. Pancreatic heterotopia; review of the literature and report of 41 authenticated surgical cases, of which 25 were clinically significant. Surg Gynecol Obstet. 1946; 82:527–542.

5. Kinoshita H, Yamaguchi S, Shimizu A, Sakata Y, Arii K, Mori K, et al. Adenocarcinoma arising from heterotopic pancreas in the duodenum. Int Surg. 2012; 97:351–355.

6. Jennings BS, Doerr RJ. Duodenal lipoma causing intussusception. Surgery. 1989; 105:560–563.

7. Lempke RE. Intussusception of the duodenum: report of a case due to Brunners gland hyperplasia. Ann Surg. 1959; 150:160–166.

8. Liu YM, Shen HP, Li X, Gong JP. Heterotopic pancreas: a clinical analysis of nine patients and review of literature. Am Surg. 2012; 78:E141–E143.

9. Ormarsson OT, Gudmundsdottir I, Mårvik R. Diagnosis and treatment of gastric heterotopic pancreas. World J Surg. 2006; 30:1682–1689.

10. Armstrong CP, King PM, Dixon JM, Macleod IB. The clinical significance of heterotopic pancreas in the gastrointestinal tract. Br J Surg. 1981; 68:384–387.

11. Yoon HC, Koh YS, Kim JC, Cho CK, Kim HJ, Lee WS, et al. Ectopic pancreas presenting as a duodenal obstructing mass. J Korean Surg Soc. 2005; 68:65–68.

12. Ogata H, Oshio T, Ishibashi H, Takano S, Yagi M. Heterotopic pancreas in children: review of the literature and report of 12 cases. Pediatr Surg Int. 2008; 24:271–275.

13. Soltero MJ, Bill AH. The natural history of Meckel's diverticulum and its relation to incidental removal. A study of 202 cases of diseased Meckel's diverticulum found in King County, Washington, over a fifteen year period. Am J Surg. 1976; 132:168–173.

14. Cullen JJ, Kelly KA, Moir CR, Hodge DO, Zinsmeister AR, Melton LJ 3rd. Surgical management of Meckel's diverticulum. An epidemiologic, population-based study. Ann Surg. 1994; 220:564–568. discussion 568-9