Gastric heterotopia presenting as a mass in jejunum

Archives of Pathology & Laboratory Medicine,  Apr 2003  by Bhattacharya, Baishali,  Jakate, Shiriam,  Saclarides, Theodore J,  Keshavarzian, Ali

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The patient was a 52-year-old woman who had previously undergone surgeries for Meckel diverticulum at age 22, volvulus of the small bowel at age 36, and hysterectomy at age 42. She presented with symptoms of intermittent cramping, abdominal pain, and vomiting. Small bowel stricture/adhesion was the working diagnosis. However, a small bowel follow-through showed a polypoid mass in the proximal jejunum, 15 to 20 cm distal to the ligament of Treitz. The mass appeared as a 3-cm polypoid filling defect with a smooth outline. She underwent an exploratory laparotomy with partial resection of jejunum containing the polypoid mass and end-to-end anastomosis.

On gross examination, the specimen consisted of an 8cm segment of jejunum with a circumference of 6 cm and a wall thickness of 0.3 cm. The central part of the segment showed a 4.0 x 2.7 x 0.4-cm mucosal, tan-brown, soft, broad-based, polypoid mass. The mucosa over the mass was finely nodular with the mucosal fold arranged differently from the surrounding jejunum (Figure 1). The remaining specimen was free of lesions. Histologically, the lesion consisted of sharply demarcated well-differentiated gastric antrofundic mucosa with chief cells, parietal cells, and mucus glands. The overlying epithelium was gastric foveolar epithelium (Figures 2 and 3). Although mildly inflamed, Helicobacter organisms were absent. There was no intestinal metaplasia, dysplasia, or neoplasia. A diagnosis of gastric heterotopia was rendered. The patient made an uneventful recovery and was discharged home on the fifth postoperative day.

Heterotopia is the presence of mature tissue in a location where it is not normally found. Gastric heterotopias have been described in various locations of the gastrointestinal tract, such as in the esophagus (inlet patch), duodenum, gallbladder, Meckel diverticulum, and elsewhere in the small bowel and rectum. Gastric heterotopias presenting as a tumorlike mass in the jejunum is an uncommon event. In a review by Lee et al,1 7 cases of gastric heterotopias of the jejunum presenting as masses (1.5-8 cm) were described. Gastric heterotopias of the small intestine can be asymptomatic, or they can present with symptoms of intestinal obstruction, ulceration, bleeding, perforation, intussusception, and pain.2,3 No case of malignant transformation has yet been reported.3 Grossly, the heterotopias present as polypoid or rugose masses and can be single or multiple.

It is important to differentiate heterotopias from metaplasias. 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 metaplasias imply an acquired condition. The lower esophagus and duodenal bulb are common sites of gastric metaplasias occurring as a protective response to the injurious action of gastric acid. Heterotopic gastric mucosae consist of full mucosal thicknesses of specialized gastric glands composed of chief and parietal cells lined by foveolar epithelium. Thus, whereas heterotopias form a perfect mucosal island, metaplasias are of partial thickness and intermingle with the native tissue. Gastric heterotopias are macroscopic lesions seen on gastrointestinal radiographs or endoscopy and confirmed by biopsies, in contrast to the microscopic nature of metaplasias.4

To summarize, we describe a 4-cm gastric heterotopic mass of the jejunum presenting with small bowel obstruction.

References

1. Lee SM, Mosenthal WT, Weismann RE, Hanover NH. Tumorous hetrotopic gastric mucosa in the small intestine. Arch Surg. 1970;100:619-622.

2. Kundrotas LW, Camara DS, Meenaghan MA, Montes M, Wosick WF, Weiser MM. Heterotopic gastric mucosa: a case report. Am J Gastroenterol. 1985;80: 253-256.

3. Briggs FL, Moore JP. Heterotopic gastric mucosa of the small bowel with perforated ulcer. Am Surg. 1979;45:413-417.

4. Mann NS, Mann SK, Rachut E. Heterotopic gastric tissue in the duodenal bulb. J Clin Gastroenterol. 2000;30:303-306.

Baishali Bhattacharya, MD; Shriram Jakate, MD; Theodore J. Saclarides, MD; Ali Keshavarzian, MD

Accepted for publication November 12, 2002.

From the Departments of Pathology (Drs Bhattacharya and Jakate), Surgery (Dr Saclarides), and Gastroenterology (Dr Keshavarzian), Rush-- Presbyterian-St Luke's Medical Center, Chicago, III.

Reprints: Baishali Bhattacharya, MD, Department of Pathology, Rush-- Presbyterian-St Luke's Medical Center, 1653 W Congress Pkwy, Jelke 570, Chicago, IL 60612 (e-mail: baishalib@hotmail.com).

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