LAUSR

Heterotopic pancreas (HP), less accurately known as ectopic, accessory or aberrant pancreas is an isolated, firm, somewhat lobulated, nodule that is anatomically separate from the normal pancreas. It is present in at least 1% of individuals and is most often found in the wall of the stomach, duodenum or a Meckel diverticulum but can be present elsewhere in the small bowel, oesophagus, appendix or other intra-abdominal viscera. In the gastrointestinal tract, HP is most often submucosal rather than subserosal and may extend into the muscularis propria to a variable degree. In children, HP is usually asymptomatic and detected incidentally but may rarely cause intussusception, gastric outlet obstruction or gastrointestinal bleeding. Malignant degeneration in this age group is exceedingly uncommon. We report a boy with heterotopic pancreatitis causing gastric outlet obstruction. An 8-year old boy presented to hospital with recurrent coffee ground vomiting. As a neonate, he had undergone repair of oesophageal atresia and a tracheo-oesophageal fistula. An upper gastrointestinal endoscopy revealed circumferential erosive oesophagitis in the mid oesophagus and he was treated with oral Omeprazole. Nine days later he returned with upper abdominal pain and vomiting. Laboratory analysis revealed a plasma lipase of 600 U/L and CRP of 60 mg/L. An abdominal CT scan showed focal thickening of the gastric antrum with an adjacent triangular wedge of tissue suggestive of heterotopic pancreas (Fig. 1). He was initially managed conservatively with intravenous fluids, analgesia and nasogastric drainage. Total parenteral nutrition was started because of persistent large nasogastric losses. A repeat CT scan 1 week later revealed multiple pseudocysts around the porta hepatis and anterior to the liver. The patient had ongoing abdominal pain, persistent large volume gastric losses and continuing raised inflammatory markers and plasma lipase. An MRI scan showed acutely inflamed heterotopic pancreatic tissue anterior to the pancreatic head adjacent to the duodenal bulb. There was an associated circumferential fluid collection around the pylorus with gastric outlet obstruction. The pancreas appeared normal. After 3 weeks of failed conservative management a laparotomy was performed. Multiple large inflammatory pseudocysts around the liver, pylorus and within the lesser sac were drained. The gallbladder was thick walled and distended. A 3 cm long firm pyramidal wedge of heterotopic pancreas was fused to the serosa of the anterior wall of the first part of the duodenum (Fig. 2). A small pancreatic duct entering the heterotopic pancreas from the duodenum was ligated.