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Ectopic pancreas and intestinal volvulus

Diana Carina Lima Gomes1  
,  
Rui Escaleira2
,  
Telma Brito1
,  
Conceição Monteiro3
,  
Alberto Midões4

1 Resident of General Surgery at the Unidade Local de Saúde do Alto Minho (ULSAM), Estr. de Santa Luzia 50, Viana do Castelo, Portugal

2 Attending Surgeon at the Unidade Local de Saúde do Alto Minho (ULSAM), Estr. de Santa Luzia 50, Viana do Castelo, Portugal

3 Graduated Attending Surgeon at the Unidade Local de Saúde do Alto Minho (ULSAM), Estr. de Santa Luzia 50, Viana do Castelo, Portugal

4 Director of Surgical Department at the Unidade Local de Saúde do Alto Minho (ULSAM), Estr. de Santa Luzia 50, Viana do Castelo, Portugal

Address correspondence to:

Diana Carina Lima Gomes

Resident of General Surgery at the Unidade Local de Saúde do Alto Minho (ULSAM), Estr. de Santa Luzia 50, Viana do Castelo,

Portugal

Message to Corresponding Author


Article ID: 101070Z01DG2019

doi: 10.5348/101070Z01DG2019CR

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How to cite this article

Gomes DCL, Escaleira R, Telma B, Monteiro C, Midões A. Ectopic pancreas and intestinal volvulus. Int J Case Rep Images 2019;10:101070Z01DG2019.

ABSTRACT

No Abstract

Keywords: Ectopic pancreas, Intestinal malrotation and occlusion

Case Report

A 39-year-old man, with no previous pathology, started with epigastric pain two months ago. He described that the pain irradiated into the back and was associated with postprandial vomiting.

Due to the increased severity of the pain, the patient went to our Emergency Department and preformed complementary examinations:

  1. Abdominal and pelvic computed tomography (CT) described a volvulus in the duodenal–jejunal transition with evidence of intestinal malrotation with the corkscrew sign (Figure 1A); inversion of the superior mesenteric vein and artery (Figure 1B); complete abdominal rotation with the colon on the right and the Treitz also on the right (Figure 1C). These findings were associated with duodenal and gastric dilation upstream. There was also the presence of a nodular lesion at the pyloric region with nearly 22 mm (Figure 2).
  2. Upper endoscopy: presence of a polypoid mass with a central umbilicus localized in the great curvature of the prepyloric region.

This patient was proposed to surgical treatment and during the surgery there were the following findings:

  • Malrotation of the small bowel with the Treitz on the right; torsion of the first jejunal loop due to the presence of fibroelastic and subserosal tumefaction with approximately 3 cm localized within the mesenteric side of the jejunum. The surgeons proceeded to the untwist of the small bowel and a segmentar enterectomy in the place where the lesion was localized.
  • Histology described a submucosal nodule compatible with an ectopic pancreas without sign of malignant cells.
Figure 1: (A) Contrast CT. The corkscrew sign with intestinal malrotation. (B) The corkscrew sign with inversion of the duodenal–jejunal. (C) Complete rotation with the colon on the right.

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Figure 2: Gastric and duodenal dilation upstream with identification of the nodular lesion at the pyloric region.

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Discussion

The ectopic pancreas is defined by the presence of pancreatic tissue outside its normal position without vascular or anatomic continuity with the body of the pancreatic gland [1]. This is a very rare congenital anomaly, with an estimated incidence of 0.6–13.7% in the world population [1],[2].

In the majority of the cases this condition is asymptomatic and only diagnosed when performing a laparotomy. The most common symptom is the presence of abdominal pain due to the irritating action of the pancreatic enzymes. In this particular case, the patient had a clinical picture compatible with an intestinal occlusion. This usually is associated with a greater amount of ectopic tissue, superior to 1.5 cm [3].

The most frequent location is at the gastric, duodenum or jejunum submucosa.

Diagnosing this pathology can be very challenging due to the similar behavior of tumor lesions. Surgical resection is always indicated. The definitive diagnosis can only be established after histological analysis [1],[2],[3].

There are very rare cases where this kind of lesion appears at the subserosal level, presenting as a focal, spheric formation at the duodenojejunal junction which was responsible for the intestinal malrotation and occlusion of the bowel in this case.

Conclusion

This is a very particular case in which the patient had two locations of ectopic pancreatic tissue: one was at the stomach (submucosal, recognized as the “vulcano sign”) and the other one was subserosal in the transition of the duodenum to the jejunum. The latest was responsible for the intestinal malrotation.

REFERENCES

1.

Jarnagin WR, Belghiti J, Büchler MW, et al. Blumgart’s Surgery of the Liver, Biliary Tract, and Pancrea. 5ed. Philadelphia, PA: Elsevier Saunders; 2012.   Back to citation no. 1  

2.

Yeo JC, McFadden DW, Pemberton JH, Peters JH, Matthews JB. Shackelford’s Surgery of the Alimentary Tract. 7ed. Philadelphia, PA: Elsevier Saunders; 2013.   Back to citation no. 1  

3.

Sathyanarayana SA, Deutsch GB, Bajaj J, et al. Ectopic pancreas: A diagnostic dilemma. Int J Angiol 2012;21(3):177–80. [CrossRef] [Pubmed]   Back to citation no. 1  

SUPPORTING INFORMATION

Acknowledgments

I appreciate the effort and collaboration of all the above authors mentioned in the conception of this article.

Author Contributions

Rui Escaleira - Conception of the work, Design of the work, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Diana Carina Lima Gomes - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Telma Brito - Acquisition of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Conceição Monteiro - Conception of the work, Design of the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Alberto Midões - Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Guaranter of Submission

The corresponding author is the guarantor of submission.

Source of Support

None

Consent Statement

Written informed consent was obtained from the patient for publication of this article.

Data Availability

All relevant data are within the paper and its Supporting Information files.

Conflict of Interest

Authors declare no conflict of interest.

Copyright

© 2019 Diana Carina Lima Gomes et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.


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