Archives of International Surgery

CASE REPORT
Year
: 2013  |  Volume : 3  |  Issue : 3  |  Page : 251--253

Ectopic pancreas in the ileum and rectal prolapse: A rare case and review of the literature


Gopalakrishnan Ravikumar1, Veerasamy Marimuthu2, G Ravikumar Naveen Prasad1,  
1 Department of Plastic Surgery, Thanjavur Medical College, Thanjavur, Tamil Nadu, India
2 Department of Surgery, Thanjavur Medical College, Thanjavur, Tamil Nadu, India

Correspondence Address:
Gopalakrishnan Ravikumar
No. 54, Shanthi Nagar, Thanjavur - 613 006, Tamil Nadu
India

Abstract

Ectopic pancreas in the ileum is a rare entity. Herein, we present a 45-year-old male admitted with complete rectal prolapse. Clinical evaluation of the patient did not reveal any predisposing factor. During abdominal rectopexy a nodule in the ileum was found which was excised and histologically reported as an ectopic pancreas. The simultaneous occurrence of rectal prolapse and ectopic pancreas in the ileum has not been reported in the literature. We present this case for its rarity and to inform that a thorough examination of the abdomen should be done to detect such incidental pathology.



How to cite this article:
Ravikumar G, Marimuthu V, Prasad G R. Ectopic pancreas in the ileum and rectal prolapse: A rare case and review of the literature.Arch Int Surg 2013;3:251-253


How to cite this URL:
Ravikumar G, Marimuthu V, Prasad G R. Ectopic pancreas in the ileum and rectal prolapse: A rare case and review of the literature. Arch Int Surg [serial online] 2013 [cited 2020 Feb 22 ];3:251-253
Available from: http://www.archintsurg.org/text.asp?2013/3/3/251/129581


Full Text

 Introduction



Ectopic pancreas is an uncommon entity. [1] It is usually detected incidentally and may be associated with complications related to the pathologic conditions of the pancreas itself but may also present with complications such as inflammation, bleeding, obstruction or malignant transformation. [1] Ectopic pancreas in the ileum is a rare entity. The incidence is about 3.8%. [2] We report a patient with rectal prolapse in whom a nodule in ileum was discovered during the abdominal rectopexy and later found to be ectopic pancreas. The simultaneous occurrence of rectal prolapse and ectopic pancreas in ileum has not been previously reported in the literature. Hence, this case is presented to stress the importance of thorough exploration during laparotomy.

 Case Report



The present case report is about a 45-year-old patient who was admitted with a mass descending per rectum of 2 years duration with non-reducibility of 1 day duration. Patient did not have any predisposing factors like chronic respiratory illness like tuberculosis or chronic obstructive pulmonary disease or constipation. Abdominal examination revealed no mass, ascites or signs of acute abdomen. Rectal examination revealed complete rectal prolapse with mucosal edema and congestion. The projecting mucosa was felt in continuity with the perianal skin and there was no deep groove between the protruding mass and the anal margin. Hence, the diagnosis of prolapsed intussusceptions was ruled out. No attempt was made to reduce conservatively to avoid shock and mucosal gangrene. Under anesthesia the rectal prolapse was reduced as an emergency procedure. Hematological and biochemical investigations were within the normal limits. Plain X-ray abdomen and chest were normal. Ultra-sonogram of the abdomen and pelvis showed no significant pathology. Thorough pre-operative assessment and bowel preparation of the patient was done. With a diagnosis of complete prolapse of the rectum abdominal rectopexy was carried out. The rectum was mobilized and fixed to the sacrum with a sheet of polypropylene mesh. Incidentally a well circumscribed sub-serosal nodule of 3 cm × 2 cm [Figure 1] was found in the ileum about 20 cm from ileo-caecal junction. Differential diagnosis of GIST or lymphoma was made. Wedge excision of segment of ileum with end to end anastomosis was done. Mesenteric node biopsy was also done.{Figure 1}

Histopathology [Figure 2] revealed pancreatic tissue consisting of acinar cells and ductal elements diffusely scattered within the sub-serosal layers of ileum suggestive of ectopic pancreas with primarily exocrine areas. Mesenteric node showed only reactive hyperplasia.{Figure 2}

 Discussion



Ectopic (hetero topic, aberrant, accessory rest) pancreas is defined as the presence of pancreatic tissue outside its usual location without any anatomical and vascular continuity with the normal pancreas proper. [2],[3] It has a genetic make-up, physiologic function and local environmental exposure similar to that of pancreas. [1] Ectopic pancreatic tissue is often found incidentally in patients operated on for other reasons or during autopsies. The incidence is 0.6-15%, mostly encountered in 4-6 th decades and has a male preponderance. [2],[3] The most frequent location of ectopic pancreas is the stomach (47%) followed by jejunum (35%), duodenum (11.7%) and ileum (3.8%). [4],[6] The histological layers involved are, in the descending order of frequency the submucosa, muscularis propria and serosa. [5] The histological layer involved in our patient was sub-serosa. Histology may show any mixture of pancreatic tissue, ducts, acini and islets. Misplacement theory and metaplasia theory have been used to explain the development of ectopic pancreas. Early in fetal life, during rotation of foregut and fusion of dorsal and ventral parts of the pancreas, small parts are separated from it and continue to develop in the wrong location.

Heinrich's classification of ectopic pancreas divides it into three types as follows:

Type 1: Ectopic pancreas tissue with acini, ducts and islets.Type 2: Few acini, multiple ducts, endocrine elements are absent.Type 3: Ductal cells are surrounded by smooth muscle. Both exo and endocrine elements are absent.

Our patient had Type 1, which is the most common histological presentation.

Jean-Schultz was the first to report ectopic pancreas. [7],[8] Clinically most often asymptomatic, rarely presented with pancreatitis and pseudocyst formation. [9] Malignancy is rare, only 10 cases are reported so far. [10] The diameter of ectopic pancreas is usually about 1-2 cm and in our case the diameter was 3 cm × 2 cm.

 Conclusion



Based on the above case it can be suggested that ectopic pancreas in the ileum is rare. Simultaneous occurrence of rectal prolapse and ectopic pancreas has not been previously reported. Hence, this case is presented to stress the importance of careful exploration during laparotomy.

References

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