At the Focal Point
Heterotopic pancreas of the jejunum diagnosed by double-balloon enteroscopy
As part of his medical evaluation, a 53-year-old man underwent an EGD that revealed multiple submucosal tumors in the second portion of the duodenum. Threedimensional CT by using an Aquilion 4-detector row CT scanner (Toshiba Medical Systems Co, Tokyo, Japan) showed multiple duodenal cysts and a soft tissue mural nodule in the proximal jejunum. The images were reconstructed by using an Aquarius workstation (TeraRecon, Inc, Tokyo, Japan) to create a 3-dimensional endoluminal fly-through image, which revealed a caterpillar-like submucosal tumor in the proximal jejunum (A). Video enteroscopy (EC-450BI5; Fujinon-Toshiba ES System Co, Tokyo, Japan) confirmed a caterpillar-like submucosal tumor in the jejunum, the top of which was focally depressed
(B). Subsequent EUS with a 20-MHz catheter probe (UM3R; Olympus Optical Co, Ltd, Tokyo, Japan) showed a mixed echogenic mass with an ill-defined margin in the submucosal layer and a small cystic component (C, arrow). A biopsy specimen showed intestinal mucosa with pancreatic acini and ducts, indicating that the tumor was heterotopic pancreas (D, H&E, orig. mag. 500). The patient did not have any GI symptoms; therefore, it was decided to follow-up the lesion with periodic imaging studies.
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DISCLOSURE The authors have no disclosures to make.
At the Focal Point
Daisuke Tsurumaru, MD, Takashi Utsunomiya, MD, PhD, Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka City; Koji Kayashima, MD, PhD, Kayashima Clinic, Fukuoka City; Shuji Matsuura, MD, PhD, Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka City; Yunosuke Nishihara, MD, Takashi Yao,
MD, PhD, Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Fukuoka City; Hiroyuki Irie, MD, PhD, Hiroshi Honda, MD, PhD, Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka City, Japan doi:10.1016/j.gie.2007.06.015
Commentary Heterotopic (ectopic) pancreas is a well-described phenomenon in which pancreatic tissue is found outside of the normal gland, usually in the upper digestive tract. When autopsies were performed as a matter of routine, these ectopia were documented in up to 14% of autopsies and most commonly found in the stomach and jejunumdnot in the colon! Such tissue is susceptible to all the ills of the normal pancreas, and in addition, ulceration, obstruction, and intussusception may result. Carcinoma arising from the heterotopic epithelium need not be a major concern, and there are only about 30 such cases reported in the literature. Heterotopic pancreas usually resembles normal pancreatic tissue, and, when present under the mucosa, may exhibit a central umbilication resulting from a subjacent pancreatic duct. As for the caterpillar-like appearance, I can only surmise that perhaps the shape was in part created by repeated peristaltic movement. Of one thing we can be sure, neither molts nor mitoses will result in emergence of a butterfly. Lawrence J. Brandt, MD Associate Editor for Focal Points
Abscess from a hernia mesh presenting as a colon mass
A 55-year-old woman was referred for a colonoscopy to evaluate chronic dull pain in the right lower quadrant of the abdomen. Three years earlier she had an appendectomy for a perforated appendix, and a year later required mesh repair of a ventral abdominal hernia in the right lower quadrant. Two weeks after the hernia surgery, she presented with an intra-abdominal abscess that ultimately resolved with antibiotics. During colonoscopy, an ulcerated mass was seen protruding into the lumen just distal to the cecum (A). Endoscopic biopsy specimen showed granulation tissue. A CT of the abdomen and pelvis disclosed a 2.5-cm ring-enhancing mass contiguous with the abdominal wall and cecum with adjacent foreign body material (B). At the time of surgery, an abscess associated with the mesh was www.giejournal.org
identified and found to be densely adherent to the bowel in the ileocecal region. Ileocecal resection and excision of the mesh were performed. Pathology showed abscess formation within the colon wall with complete perforation near the mesh attachment. DISCLOSURE The authors have no disclosures to make. Robert Wong, MD, Division of Gastroenterology; Daniel Vargo, MD, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah, USA doi:10.1016/j.gie.2007.05.039
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