Case Report | Open Access
Siri A. Urquhart, Nayantara Coelho-Prabhu, "Jejunal Polyps out of Place: A Case of Gastric Heterotopia of the Jejunum", Case Reports in Gastrointestinal Medicine, vol. 2020, Article ID 8822019, 4 pages, 2020. https://doi.org/10.1155/2020/8822019
Jejunal Polyps out of Place: A Case of Gastric Heterotopia of the Jejunum
Heterotopia is the presence of normal physiologic tissue in an atypical location. Gastric heterotopia has been described in various locations throughout the gastrointestinal tract, including the small intestine. Gastric heterotopia of the small intestine typically is asymptomatic but may present in several ways with symptoms of obstruction, bleeding, perforation, intussusception, or pain. However, gastric heterotopia is rare beyond the duodenum except for its frequent association with Meckel’s diverticulum. This entity should be considered in the differential diagnosis of polypoid lesions presenting with symptoms of bleeding or obstruction especially in younger patients. We present a case of gastric heterotopia of the jejunum in a patient with a prior history of Meckel’s diverticulectomy after he presented with obstructive symptoms. His symptoms improved following resection of two jejunal polyps via antegrade double-balloon assisted enteroscopy with fluoroscopy. On histopathlogical examination, findings were consistent with gastric heterotopia. This case highlights the importance of considering gastric heterotopia in the differential diagnosis of polypoid lesions located beyond the ligament of Treitz in younger patients presenting with obstructive symptoms.
Heterotopia is the presence of mature physiologic tissue in an atypical location. Gastric heterotopia has been described in several locations throughout the gastrointestinal tract such as the esophagus, duodenum, gallbladder, Meckel’s diverticulum, and other areas within the small bowel and rectum. Gastric heterotopia of the small intestine can be asymptomatic or present in various ways with symptoms of obstruction, ulceration or bleeding, perforation, intussusception, or pain . Gastric heterotopia beyond the ligament of Treitz is rare but should be considered in the differential diagnosis of polypoid lesions in young patients presenting with gastrointestinal bleeding or symptoms of obstruction .
2. Case Presentation
A 33-year-old gentleman presented with lower abdominal pain, occasional nausea, emesis, and inability to pass stool or flatus. He did not have any fever or chills. His past medical history was notable for Meckel’s diverticulectomy secondary to gastrointestinal bleeding which ultimately required ileal resection and stapled anastomosis ten years previously. The pathology following operative intervention did not demonstrate any ectopic gastric mucosa. He did not have any additional pertinent past medical, family, or social history.
His vital signs were within normal limits. Physical examination was notable for a minimally distended abdomen with tympany on percussion. Laboratory investigations were unremarkable. Coronal and axial computed tomography enterography of the abdomen and pelvis with contrast (Figure 1) demonstrated a 0.8 cm jejunal polyp in the proximal jejunum just past the ligament of Treitz. He subsequently underwent an antegrade double-balloon assisted enteroscopy with fluoroscopy which revealed a 1.5 cm semisessile polyp without bleeding at the ligament of Treitz in addition to a 0.7 cm sessile polyp in the proximal jejunum (Figure 2) which were then resected. Histopathology demonstrated nodular areas of gastric fundic heterotopia without dysplasia. Oxyntic glands with chief cells (arrows) and parietal cells (asterisks) are shown at high magnification (Figure 3). A diagnosis of gastric heterotopia of the jejunum was made. Following endoscopic resection, the patient was advised to avoid aspirin or nonsteroidal anti-inflammatory medications and to monitor hemoglobin annually for anemia.
Heterotopia is defined as the presence of normal physiologic tissue in an anatomic location where it is not normally found. Gastric heterotopia is not an uncommon lesion and can be found in several areas throughout the gastrointestinal tract. However, gastric heterotopia is rare beyond the duodenum except for its frequent association with Meckel’s diverticulum . Gastric heterotopia of the small intestine may be asymptomatic or present with symptoms of intestinal obstruction, ulceration or bleeding, perforation, intussusception, or pain . Gross appearance is characteristically a mucosal nodularity or polypoid lesion [2, 4]. Peptic ulceration in the area of heterotopia followed by inflammation and fibrosis may result in the formation of a stricture. Polyps can cause intussusception. On microscopic examination, the surface is lined by gastric foveolar epithelium with gastric glands, typically with fundic type mucosa .
It is important to differentiate gastric heterotopia from gastric metaplasia. Gastric metaplasia is an acquired lesion and is usually seen in association with chronic inflammatory conditions such as inflammatory bowel disease. Unlike heterotopia which is a macroscopic lesion seen on radiographic imaging or endoscopy, ultimately requiring confirmation by biopsy, metaplasia is a microscopic lesion .
The typical treatment for gastric heterotopia includes endoscopic or surgical resection to prevent complications. This case is unique in that the patient had two foci of gastric tissue outside of the stomach with a prior history of Meckel’s diverticulectomy and prior pathology at the time of small bowel resection without any evidence of ectopic gastric mucosa.
It is important to recognize the variety of presentations associated with gastric heterotopia. A timely diagnosis of an enlarged polyp can prevent complications such as obstruction, intussusception, bleeding, or perforation. The combination of clinical presentation, radiologic imaging, and endoscopic and pathologic evaluation is helpful in making the diagnosis .
In most reported cases of gastric heterotopia involving the jejunum (Table 1), patients had a median age of 21.5 years with the youngest patient being one-year-old . Presenting symptoms consisted of gastrointestinal bleeding [7–9] or obstructive symptoms as a result of a polypoid mass [1, 5, 10–17] and stricture [2, 3, 6]. One case report described a 16-year-old patient who developed perforation and ulceration involving the jejunum in the setting of gastric heterotopia . One case report described a 21-year-old patient with a 15 cm intraluminal polypoid mass involving the jejunum , while two case reports described multiple strictures associated with jejunal gastric heterotopia [2, 6]. Gastric heterotopia was not suspected clinically in any of these cases and was diagnosed on histopathological examination.
Gastric heterotopia can present in various ways including masslike lesions with symptoms of obstruction, pain, or bleeding, or may even remain asymptomatic. Gastric heterotopia beyond the ligament of Treitz is a rare entity. This case highlights the importance of considering gastric heterotopia in the differential diagnosis of polypoid lesions located beyond the ligament of Treitz in younger patients presenting with obstructive symptoms .
No data were used to support this study.
Conflicts of Interest
The authors declare no conflicts of interest.
- B. Bhattacharya, S. Jakate, T. J. Saclarides, and A. Keshavarzian, “Gastric heterotopia presenting as a mass in jejunum,” Archives of Pathology & Laboratory Medicine, vol. 127, no. 4, pp. 506-507, 2003.
- M. Vani, A. Nambiar, K. Geetha, and B. Kundil, “Jejunal gastric heterotopia causing multiple strictures and perforation peritonitis: a case report with review of literature,” Journal of Clinical and Diagnostic Research, vol. 11, no. 3, pp. ED11–ED12, 2017.
- G. E. Chinnery, M. M. Bernon, M. A. Banderker, R. Roberts, and J. E. J. Krige, “Gastric heterotopia causing jejunal ulceration and obstruction,” South African Journal of Surgery, vol. 51, no. 4, pp. 146-147, 2013.
- J. Cai and H. Yu, “Giant polypoid gastric heterotopia in the small intestine in a boy: a case report and literature review,” Medicine, vol. 96, no. 1, Article ID e5854, 2017.
- A. Nasir, S. K. Amateau, S. Khan, R. W. Simpson, D. C. Snover, and K. Amin, “The many faces of intestinal tract gastric heterotopia; a series of four cases highlighting clinical and pathological heterogeneity,” Human Pathology, vol. 74, pp. 183–187, 2018.
- S. Al-Jadaan and O. Oda, “A rare clinical presentation of heterotopic gastric mucosa of the jejunum: a case report and review of the literature,” Journal of Pediatric Surgery Case Reports, vol. 2, no. 7, pp. 337–340, 2014.
- S. M. Ali, A. A. Ahmed, L. Saaid et al., “Heterotopic gastric mucosa presenting as lower gastrointestinal bleeding: an unusual case report,” Case Reports in Surgery, vol. 2019, Article ID 5791984, 4 pages, 2019.
- J. C. Jimenez, S. Emil, B. Steinmetz, S. Romansky, and M. Weller, “Recurrent gastrointestinal tract bleeding secondary to jejunal gastric heterotopia,” Journal of Pediatric Surgery, vol. 40, no. 10, pp. 1654–1657, 2005.
- S. Leng, M. Ghionzoli, C. Caporalini, and A. M. Buccoliero, “Long-term intestinal bleeding in a child: a rare case of heterotopic gastric mucosa in the jejunum,” BMJ Case Reports, vol. 2016, 2016.
- K. R. Ahn, J. S. Koo, H. I. Kim et al., “Endoscopic treatment of Jejunal heterotopic gastric mucosa that caused recurrent intussusception,” Clinical Endoscopy, vol. 50, no. 6, pp. 605–608, 2017.
- M. J. Khan, P. Mullerat, and A. Desai, “A polypoid gastric heterotopia of jejunum diagnosed by capsule endoscopy,” Journal of the College of Physicians and Surgeons, vol. 19, no. 10, pp. 661-662, 2009.
- A. R. Kimpton and A. R. Crane, “Heterotopic gastric mucosa,” New England Journal of Medicine, vol. 218, no. 15, pp. 627–629, 1938.
- S. M. Lee, W. T. Mosenthal, and R. E. Weismann, “Tumorous heterotopic gastric mucosa in the small intestine,” Archives of Surgery, vol. 100, no. 5, pp. 619–622, 1970.
- S. R. Mandrekar, A. Sangeeta, N. Sanjyot, and R. G. Pinto, “Giant polypoid gastric heterotopia of jejunum,” Medical Journal of Dr. D. Y. Patil University, vol. 9, no. 5, pp. 645–647, 2016.
- A. Martínez, O. Decanini-Terán, and D. Soria-Céspedes, “Polypoid and hyperplastic heterotopic gastric mucosa in the jejunum as a cause of recurrent subocclusive episodes,” Annals of Gastroenterology, vol. 26, no. 2, p. 184, 2013.
- J. Nwanze, V. Collins, B. Crawford, and Y. Nakanishi, “A case of small bowel intussusception in an adult caused by heterotopic gastric mucosa in the Jejunum: a case report and review of the literature,” American Journal of Clinical Pathology, vol. 150, no. 1, p. S43, 2018.
- P. A. Omotosho, H. Varnholt, M. V. Tirabassi, R. Prasad, and K. P. Moriarty, “Giant polypoid gastric heterotopia of the jejunum presenting with intermittent intussusception,” Journal of Laparoendoscopic & Advanced Surgical Techniques, vol. 17, no. 2, pp. 249–251, 2007.
- W. H. Isbister and D. Weedon, “Perforated jejunal ulcer and heterotopic gastric mucosa,” British Journal of Surgery, vol. 63, no. 12, pp. 954-955, 1976.
Copyright © 2020 Siri A. Urquhart and Nayantara Coelho-Prabhu. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.