Suprainfected Heterotopic Pancreatic Tissue: A Rare Culprit of Recurrent Gastric Outlet Obstruction

Document Type

Conference Proceeding

Publication Date

10-1-2024

Publication Title

Am J Gastroenterol

Abstract

Introduction: Pancreatic rest (PR) is an uncommon finding of ectopic pancreatic tissue that can be located throughout the gastrointestinal tract and is commonly asymptomatic. However, when symptoms develop, they can cause severe complications that include pancreatitis and gastrointestinal obstruction. Here we report a rare case of supra-infected pancreatic rest tissue in the gastric antrum, leading to recurrent gastric outlet obstruction. Case Description/Methods: A 30-year-old woman presents with a 6-month history of worsening abdominal pain, nausea and vomiting refractory to proton pump inhibitor therapy. Index upper endoscopy (EGD) showed a subepithelial nodule in the pylorus, with central umbilication and stenosis in the first portion of the duodenum (Figure 1A). The patient developed recurrent symptoms and underwent 2 EGDs, 1 and 7 months later with serial balloon dilations of the duodenal stenosis to 10 mm and 12.5 mm respectively. Due to persistent stenosis and recurrent symptoms, endoscopic ultrasound (EUS) was performed twice, initially showing a well-defined (23 x 12 mm, Figure 1B) subepithelial lesion in the gastric antrum consistent with pancreatic rest and a second (24 x 14 mm, Figure 1C) subepithelial lesion in the pylorus causing stenosis, fine needle aspiration (FNA) consistent with abscess. Repeat EUS 10 months later showed persistent intramural abscess (27 x 23 mm) with extrinsic compression on the pylorus, repeat FNA drainage was performed. Magnetic resonance imaging abdomen 1 month post-EUS FNA showed an 11 mm distal gastric intramural abscess (Figure 1d) and heterotopic pancreatic tissue emanating from the pancreatic head and extending along the stomach inferior to the abscess (Figure 1e). Patient was treated with multiple courses of antibiotics that resulted in symptom improvement, but continued to develop symptom recurrence after antibiotic discontinuation. Given severe symptoms with recurrent episodes refractory to medical therapy, she was referred to surgical oncology to evaluate for resection. Discussion: This case describes the rare development of recurrent gastric outlet obstruction due to a suprainfected PR. It highlights the significance of recognizing the location and pathologic involvement of PR lesions to help predict and appropriately counsel patients about the potential disease course. Our patient had transmural gastric pylorus involvement, contributing to a higher risk for obstruction. Surgical evaluation should be considered in patients with recurrent severe symptoms if refractory to medical and endoscopic treatment.

Volume

119

Issue

10

First Page

S1743

Last Page

S1744

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