Table of Contents  
CASE REPORT
Year : 2016  |  Volume : 9  |  Issue : 5  |  Page : 645-647  

Giant polypoid gastric heterotopia of jejunum


Department of Pathology, Goa Medical College, Bambolim, Goa, India

Date of Web Publication13-Oct-2016

Correspondence Address:
Suresh Ramchandra Shenovi Mandrekar
2874, “Seeta Ramchandra”, Naik-Nagar, Bordem, Bicholim - 403 504, Goa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.192152

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  Abstract 

Heterotopic gastric tissue has been described in various parts of the gastrointestinal tract as an incidental finding. However, its presentation as a mass in the jejunum with obstructive manifestations is a rare event. We report here a rare case of giant polypoid gastric heterotopia in the jejunum that presented with intestinal obstruction in a 22-year-old female, along with a brief review of the literature.

Keywords: Gastric heterotopia, giant polyp, jejunum


How to cite this article:
Mandrekar SR, Sangeeta A, Sanjyot N, Pinto RG. Giant polypoid gastric heterotopia of jejunum. Med J DY Patil Univ 2016;9:645-7

How to cite this URL:
Mandrekar SR, Sangeeta A, Sanjyot N, Pinto RG. Giant polypoid gastric heterotopia of jejunum. Med J DY Patil Univ [serial online] 2016 [cited 2019 Nov 14];9:645-7. Available from: http://www.mjdrdypu.org/text.asp?2016/9/5/645/192152




  Introduction Top


Heterotopia is the presence of a particular type of tissue in a place where it is not normally found.[1] Gastric heterotopias can occur throughout the entire gastrointestinal tract from the oral cavity to the anorectum and can also involve the gallbladder, biliary tract, umbilicus, and scrotum.[2] Heterotopic gastric mucosa is not uncommon in Meckel's diverticulum, or in other persisting parts of the vitellointestinal duct and in duplications, diverticula and cysts.[1] However, gastric heterotopia presenting as a tumor-like mass in the jejunum is an uncommon event.[3],[4] Gastric heterotopias of the small intestine can be asymptomatic or present with the symptoms of intestinal obstruction, ulceration, bleeding, perforation, intussusceptions, and pain.[3],[4] It is important to differentiate gastric metaplasia, which occurs in inflammatory conditions from true heterotopia which is a developmental anomaly.[5] A polypoid gastric heterotopia should be considered in the differential diagnosis of jejunal polyp presenting in childhood or adolescent period.


  Case Report Top


A 22-year-old female patient presented to casualty with intestinal obstruction. The patient underwent emergency laparotomy and resection of a segment of jejunum for a suspected tumor mass. There were no episodes of bleeding or obstructive symptoms in the past. On gross examination, the specimen received was a 23 cm segment of the jejunum. At 2 cm from the proximal end and 13 cm from the other end, there was a polypoidal mass measuring 8 cm × 6 cm × 2 cm [Figure 1]. On closer inspection, the polypoidal mass showed surface rugosity with a broad base that covered a large surface of the jejunum and had an appearance of mucosa that was different from that of surrounding jejunum with sharp demarcation [Figure 2]. On microscopic examination, the mass was composed of a full thickness of gastric mucosa with specialized gastric glands of the chief and parietal cells [Figure 3] and [Figure 4] and was lined by foveolar type of epithelium which showed focal hyperplasia [Figure 5]. Some of the glands were cystically dilated. There was no ulceration over the mass, and the surrounding jejunal mucosa was unremarkable.
Figure 1: Gross resected specimen of jejunum showing the polypoidal mass with broad base

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Figure 2: Surface of the polyp showing rugose appearance with sharp demarcation from surrounding jejunum

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Figure 3: Photomicrograph of the polyp showing full thickness gastric mucosa with some cystically dilated glands (H and E, ×100)

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Figure 4: Photomicrograph from the edge of the polyp. Arrow shows central polypoidal gastric mucosa with adjacent jejunal mucosa (H and E, ×100)

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Figure 5: Photomicrograph of the polyp showing hyperplasia of the lining gastric foveolar epithelium (H and E, ×400)

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  Discussion Top


Heterotopia from the Greek “heteros” (different) and “topos” (location) is defined as the occurrence of normal tissue in an abnormal location.[3] It is important to differentiate heterotopias from metaplasia. Metaplasia is a change of one type of fully developed tissue to another differentiated tissue usually due to sustained inflammation and its complications. Heterotopias imply a developmental anomaly, whereas metaplasia implies an acquired condition.[5]

Epithelium resembling gastric mucosa of the nonspecialized antral or pyloric type is seen in a variety of conditions for e.g., inflammatory bowel disease. This change occurs secondary to chronic inflammation and, hence, is strictly a metaplastic change.[6] Similarly, the lower esophagus and duodenal bulb are common sites of gastric metaplasia occurring as a protective response to the injurious action of gastric juice.[5]

Heterotopic gastric mucosa consists of full mucosal thickness of specialized gastric glands composed of chief and parietal cells lined by foveolar epithelium. Thus, whereas, heterotopias are a perfect mucosal island, metaplasias are of partial thickness and intermingle with the native tissue. Gastric heterotopias are macroscopic lesions on gastrointestinal radiographs or endoscopy and confirmed by biopsies, in contrast to the microscopic nature of metaplasias which are an incidental finding.[5]

Gastric heterotopia has been described throughout the entire gastrointestinal tract from the oral cavity to the anorectum and also the gallbladder, biliary tract, umbilicus, and scrotum.[2] Heterotopic gastric mucosa is not uncommon in Meckel's diverticulum, or in other persisting parts of the vitellointestinal duct and in duplications diverticula and cysts.[1] Many gastric heterotopias of the small intestine remain asymptomatic and are diagnosed incidentally after the examination of pathology specimen. Others may present with the symptoms of intestinal obstruction like the present case or may present with bleeding, perforation, penetration into adjacent organs and fistulization, intussusception, and pain.[3],[7] Rarely, failure to thrive is the clinical presentation of heterotopic gastric mucosa.[7]

Jejunal heterotopic gastric mucosa is a rare entity. It usually presents as a polypoid or rugose mass predominantly located within a few centimeters distal to the ligament of Treitz [8] and can be single or multiple.[3] The reported size ranged from 2 to 15 cm [2],[3],[5] and usually presents in an adolescent or young adult. Histologically, heterotopic gastric mucosa consists of full mucosal thickness that is sharply demarcated from surrounding jejunal mucosa and comprises well-differentiated antro-fundic mucosa with chief cells, parietal cells, and mucus glands with overlying gastric foveolar epithelium.[3],[5]

It is important to consider this entity in the differential diagnosis of polypoidal masses in the jejunum specially those which present in adolescence or young adulthood. A preoperative 99m Tc pertechnetate scan or capsule endoscopy can be helpful in the diagnosis of a suspected case. However, only pathologic review can establish the definitive diagnosis.[7]

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Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Cuvelier C. Congenital abnormalities of small intestine. In: Shepherd NA, Warren BF, Williams GT, Greenson JK, Lauwers GY, Novelli MR, editors. Morson and Dawson's Gastrointestinal Pathology. 5th ed. Wiley-Blackwell; 2013. p. 300-1.  Back to cited text no. 1
    
2.
Martínez A, Decanini-Terán O, Soria-Céspedes D. Polypoid and hyperplastic heterotopic gastric mucosa in the jejunum as a cause of recurrent subocclusive episodes. Ann Gastroenterol 2013;26:184.  Back to cited text no. 2
    
3.
Khan MJ, Mullerat P, Desai A. A polypoid gastric heterotopia of jejunum diagnosed by capsule endoscopy. J Coll Physicians Surg Pak 2009;19:661-2.  Back to cited text no. 3
[PUBMED]    
4.
Omotosho PA, Varnholt H, Tirabassi MV, Prasad R, Moriarty KP. Giant polypoid gastric heterotopia of the jejunum presenting with intermittent intussusception. J Laparoendosc Adv Surg Tech A 2007;17:249-51.  Back to cited text no. 4
    
5.
Bhattacharya B, Jakate S, Saclarides TJ, Keshavarzian A. Gastric heterotopia presenting as a mass in jejunum. Arch Pathol Lab Med 2003;127:506-7.  Back to cited text no. 5
[PUBMED]    
6.
Lessells AM, Martin DF. Heterotopic gastric mucosa in the duodenum. J Clin Pathol 1982;35:591-5.  Back to cited text no. 6
[PUBMED]    
7.
Al-Jadaan S, Oda O. A rare clinical presentation of heterotopic gastric mucosa of the jejunum: A case report and review of the literature. J Pediatr Surg Case Rep 2014;2:337-40.  Back to cited text no. 7
    
8.
Boybeyi O, Karnak I, Güçer S, Orhan D, Senocak ME. Common characteristics of jejunal heterotopic gastric tissue in children: A case report with review of the literature. J Pediatr Surg 2008;43:e19-22.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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