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Ectopic pancreas presenting as ampulla of vater tumor
The American Journal of Surgery 195 (2008) 498 –500
Clinical image
Ectopic pancreas presenting as ampulla of vater tumor Sheng-Der Hsu, M.D.a,d, De-Chuan Chan, M.D.a, Huan-Fa Hsieh, M.D.b, Teng-Wei Chen, M.D.a, Jyh-Cherng Yu, M.D.a, Shao-Jiun Chou, M.D.c,* a
Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China b Department of Surgery, Yee-Zen General Hospital, Tauyuan, Taiwan, Republic of China c Division of General Surgery, Department of Surgery, Cardinal Tien Hospital, 362 Chung Cheng Rd., Hsintien Taipei Hsien 23137, Taiwan, Republic of China d Division of General Surgery, Department of Surgery, Tri-Service General Hospital, Keelung Civilian Administration Division Manuscript received September 27, 2006; revised manuscript January 31, 2007
Abstract Ectopic pancreas is relatively rare and is defined as pancreatic tissue that is situated abnormally, has no contact with the normal pancreas, and has its own ductal system and blood supply. It is usually an incidental finding in clinical practice. Most patients with an ectopic pancreas are asymptomatic, and, if present, symptoms are nonspecific and depend on the site of the lesion and the different complications encountered. Heterotopic pancreatic tissue has been found in several abdominal and intrathoracic locations, most frequently in the stomach (25%– 60%) or the duodenum (25%–35%). Herein, we report a patient presenting with symptoms of ampullary tumor with obstructive jaundice, but the imaging study did not suggest the possibility of ectopic pancreas preoperatively. © 2008 Elsevier Inc. All rights reserved. Keywords: Ampulla of vater tumor; Ectopic pancreas
A 54-year-old man visited our emergency room because of epigastric pain, tea-colored urine, and general malaise for 3 to 4 days. Tracing his history, the pain gradually increased in severity with time, associated with eating, and was persistent in two months, worsening while lying on his right side and relieved by changing to his left side, and radiating toward the center of his back. Because of these symptoms he was admitted to the hospital for further evaluation. Abdominal sonography showed marked dilatation of bilateral intrahepatic ducts and the common bile duct. Computerized tomography showed similar results and the common bile duct (CBD) dilated up to the ampullar region (Fig. 1, arrow). Thus, a small distal CBD stone impaction or ampulla vater tumor was suspected. Further study with endoscopic retrograde cholangiopancreatography (ERCP) showed a protruding ampulla of vater with mucosa ulceration (Fig. 2), dilated CBD, as well as circumference stricture of the CBD lower end
* Corresponding author. Tel.: ⫹886-2-8792-7191; fax: ⫹886-2-87927372. E-mail address: [email protected] 0002-9610/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.01.043
suggestive of a tumor of ampulla of vater (Fig. 3). Meanwhile, a biopsy also was performed and revealed chronic inflammation. The Whipple procedure was performed because of the suspicion of a tumor of ampulla of vater. The pathohistologic report showed pictures of ectopic pancreas. Ectopic pancreas is a rare entity and usually is an incidental finding in clinical practice. Most patients with an ectopic pancreas are asymptomatic, and, if present, symptoms are nonspecific (ie, epigastric pain, ulceration, hemorrhage, and jaundice), and depend on the site of the lesion and the different complications encountered [1]. In autopsy series the frequency of ectopic pancreas is between 1% and 2%. About 75% of all pancreatic rests are located in the stomach, duodenum, or jejunum [2]. The role of endoscopic biopsies in identifying ectopic pancreas remains questionable because normal ductal mucosa covers the lesion [3]. Surgical excision, either endoscopically or laparoscopically, provides symptomatic relief and is recommended if the diagnosis remains uncertain. However, some ectopic pancreatic tissue may show the central dimpling in ERCP if the tissue is large enough or ulceration is over the lesion owing to the
S.-D. Hsu et al. / The American Journal of Surgery 195 (2008) 498 –500
499
Fig. 1. Computerized tomography scans showing the CBD dilated up to the ampullar region (arrows).
Fig. 2. ERCP showing a protruding ampulla of vater with mucosa ulceration (arrow).
Fig. 3. ERCP showing dilated CBD as well as circumference stricture of the CBD lower end (arrows) and bird bead narrowing with nearly total obstruction.
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S.-D. Hsu et al. / The American Journal of Surgery 195 (2008) 498 –500
exocrine pancreatic juice. If the patient is symptomatic, as our patient, surgical treatment is indicated. The size and location of ectopic pancreatic tissue also determines what kind of procedure should be performed. References [1] Mulholland MW, Simeone DM. Pancreas: anatomy and structural anomalies: congenital anomalies: heterotopic pancreas. In: Yamada T,
Alpers DH, Laine L, et al, eds. Textbook of Gastroenterology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999:2115–9. [2] Grendell JH, Ermak TH. Anatomy, histology, embryology, and developmental anomalies of the pancreas. In: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. Philadelphia: WB Saunders; 1998: 761–71. [3] Riyaz A, Cohen H. Ectopic pancreas presenting as a submucosal gastric antral tumor that was cystic on EUS. Gastrointest Endosc 2001;53:675–7.
Clinical image
Ectopic pancreas presenting as ampulla of vater tumor Sheng-Der Hsu, M.D.a,d, De-Chuan Chan, M.D.a, Huan-Fa Hsieh, M.D.b, Teng-Wei Chen, M.D.a, Jyh-Cherng Yu, M.D.a, Shao-Jiun Chou, M.D.c,* a
Division of General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China b Department of Surgery, Yee-Zen General Hospital, Tauyuan, Taiwan, Republic of China c Division of General Surgery, Department of Surgery, Cardinal Tien Hospital, 362 Chung Cheng Rd., Hsintien Taipei Hsien 23137, Taiwan, Republic of China d Division of General Surgery, Department of Surgery, Tri-Service General Hospital, Keelung Civilian Administration Division Manuscript received September 27, 2006; revised manuscript January 31, 2007
Abstract Ectopic pancreas is relatively rare and is defined as pancreatic tissue that is situated abnormally, has no contact with the normal pancreas, and has its own ductal system and blood supply. It is usually an incidental finding in clinical practice. Most patients with an ectopic pancreas are asymptomatic, and, if present, symptoms are nonspecific and depend on the site of the lesion and the different complications encountered. Heterotopic pancreatic tissue has been found in several abdominal and intrathoracic locations, most frequently in the stomach (25%– 60%) or the duodenum (25%–35%). Herein, we report a patient presenting with symptoms of ampullary tumor with obstructive jaundice, but the imaging study did not suggest the possibility of ectopic pancreas preoperatively. © 2008 Elsevier Inc. All rights reserved. Keywords: Ampulla of vater tumor; Ectopic pancreas
A 54-year-old man visited our emergency room because of epigastric pain, tea-colored urine, and general malaise for 3 to 4 days. Tracing his history, the pain gradually increased in severity with time, associated with eating, and was persistent in two months, worsening while lying on his right side and relieved by changing to his left side, and radiating toward the center of his back. Because of these symptoms he was admitted to the hospital for further evaluation. Abdominal sonography showed marked dilatation of bilateral intrahepatic ducts and the common bile duct. Computerized tomography showed similar results and the common bile duct (CBD) dilated up to the ampullar region (Fig. 1, arrow). Thus, a small distal CBD stone impaction or ampulla vater tumor was suspected. Further study with endoscopic retrograde cholangiopancreatography (ERCP) showed a protruding ampulla of vater with mucosa ulceration (Fig. 2), dilated CBD, as well as circumference stricture of the CBD lower end
* Corresponding author. Tel.: ⫹886-2-8792-7191; fax: ⫹886-2-87927372. E-mail address: [email protected] 0002-9610/08/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2007.01.043
suggestive of a tumor of ampulla of vater (Fig. 3). Meanwhile, a biopsy also was performed and revealed chronic inflammation. The Whipple procedure was performed because of the suspicion of a tumor of ampulla of vater. The pathohistologic report showed pictures of ectopic pancreas. Ectopic pancreas is a rare entity and usually is an incidental finding in clinical practice. Most patients with an ectopic pancreas are asymptomatic, and, if present, symptoms are nonspecific (ie, epigastric pain, ulceration, hemorrhage, and jaundice), and depend on the site of the lesion and the different complications encountered [1]. In autopsy series the frequency of ectopic pancreas is between 1% and 2%. About 75% of all pancreatic rests are located in the stomach, duodenum, or jejunum [2]. The role of endoscopic biopsies in identifying ectopic pancreas remains questionable because normal ductal mucosa covers the lesion [3]. Surgical excision, either endoscopically or laparoscopically, provides symptomatic relief and is recommended if the diagnosis remains uncertain. However, some ectopic pancreatic tissue may show the central dimpling in ERCP if the tissue is large enough or ulceration is over the lesion owing to the
S.-D. Hsu et al. / The American Journal of Surgery 195 (2008) 498 –500
499
Fig. 1. Computerized tomography scans showing the CBD dilated up to the ampullar region (arrows).
Fig. 2. ERCP showing a protruding ampulla of vater with mucosa ulceration (arrow).
Fig. 3. ERCP showing dilated CBD as well as circumference stricture of the CBD lower end (arrows) and bird bead narrowing with nearly total obstruction.
500
S.-D. Hsu et al. / The American Journal of Surgery 195 (2008) 498 –500
exocrine pancreatic juice. If the patient is symptomatic, as our patient, surgical treatment is indicated. The size and location of ectopic pancreatic tissue also determines what kind of procedure should be performed. References [1] Mulholland MW, Simeone DM. Pancreas: anatomy and structural anomalies: congenital anomalies: heterotopic pancreas. In: Yamada T,
Alpers DH, Laine L, et al, eds. Textbook of Gastroenterology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1999:2115–9. [2] Grendell JH, Ermak TH. Anatomy, histology, embryology, and developmental anomalies of the pancreas. In: Sleisenger & Fordtran’s Gastrointestinal and Liver Disease. Philadelphia: WB Saunders; 1998: 761–71. [3] Riyaz A, Cohen H. Ectopic pancreas presenting as a submucosal gastric antral tumor that was cystic on EUS. Gastrointest Endosc 2001;53:675–7.