Jejunal ectopic pancreas: a rare cause of gastrointestinal bleeding diagnosed using balloon enteroscopy

A 42-year-old man with arterial hypertension and human immunodeficiency virus (HIV) infection was admitted for investigation of melena. Blood tests revealed iron deficiency anemia (hemoglobin concentration was 4.9 g/dL). On further questioning, the patient acknowledged having experienced several months of intermittent melena and recurrent episodes of abdominal pain. He denied weight loss or other gastrointestinal symptoms. Esophagogastroduodenoscopy and colonoscopy failed to identify a source of bleeding. To complete the evaluation, video capsule endoscopy was performed, which disclosed a subepithelial tumor located in the jejunum ([Fig. 1]), without other relevant findings in the small bowel. Subsequent single-balloon enteroscopy (SIF-Q180; Olympus Medical Systems, Tokyo, Japan) was carried out through the oral insertion route. A 20-mm caterpillar-like subepithelial tumor was observed within the topography of the lesion previously described ([Video 1]), with a smooth surface and focal erythema in the mucosa ([Fig. 2]). Endoscopic tattooing was performed and the patient was referred for surgical resection. Pathologic examination revealed pancreatic acinar cells, prominent secretory ducts, and islet cells in the jejunal submucosa ([Fig. 3]), consistent with ectopic pancreas (type I, Heinrich’s classification). At 6-month follow-up, the patient remains asymptomatic.

Fig. 1 Video capsule endoscopic view of the jejunal lumen, in a 42-year-old man evaluated for obscure gastrointestinal bleeding, who presented with melena and iron deficiency anemia, showing an elevated lesion with erythematous mucosal surface (subepithelial tumor) in the jejunum.

Anterograde single-balloon enteroscopy showing a jejunal subepithelial tumor, that after insufflation revealed a caterpillar-like appearance. The subepithelial tumor was subsequently tattooed and the patient referred for surgery.

Fig. 2 Enteroscopic view of the jejunal lumen, showing a caterpillar-like subepithelial tumor with a smooth surface and focal erythema in the mucosa.

Fig. 3 Photomicrograph of the surgical specimen, demonstrating pancreatic tissue composed of acinar cells, prominent secretory ducts, and islets of Langerhans beneath a normal jejunal mucosa, consistent with heterotopic pancreas type 1 according to Heinrich’s classification (original magnification × 20; hematoxylin and eosin).

The term “ectopic pancreas” refers to pancreatic tissue that lacks anatomic and vascular connections with the parent organ [1]. Jejunal ectopic pancreas is a rare entity; it is usually asymptomatic and diagnosed incidentally by imaging. Very occasionally, it may become clinically evident when complicated by inflammation, obstruction, or bleeding, with melena and/or anemia [2], as in the present case. The enteroscopic findings have rarely been described.

We report an unusual case of obscure gastrointestinal bleeding with severe anemia due to a jejunal ectopic pancreas, detected by video capsule endoscopy and single-balloon enteroscopy. It appeared caterpillar-like on endoscopy, which has been suggested by Takeda et al. [3] and Tsurumaru et al. [4] to be characteristic of small-bowel ectopic pancreas. The differential diagnosis against other small-bowel subepithelial tumors is usually difficult [5]. Resection is the suggested treatment for complicated cases.

Endoscopy_UCTN_Code_CCL_1AC_2AH

Competing interests: None

• References

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