Heterotopic pancreas in the gall bladder.

eterotopia is the presence of tissues that are not normally found in the area. The most important of these is heterotopic or aberrant pancreatic tissue, which is a rare congenital anomaly of the gastrointestinal tract. It is usually asymptomatic and commonly encountered at autopsy or surgery in 2-10% of cases1,2 especially in the gastric antrum. Other reported locations include ileum, Meckel's diverticulum, spleen, umbilicus, bile ducts, ampulla of Vater, major duodenal papilla, colon, mesentery and even the omentum.3 There is less than 30 reported cases of aberrant pancreas in the gall bladder wall in the reviewed world English literature. We report here a case of a 23-year-old Saudi housewife presented with 4-month history of intermittent upper abdominal pain, which radiates to the back and was associated with fatty food intolerance. The pain became very severe and was associated with nausea and vomiting a day prior to admission. She denied any history of jaundice, sickle cell disease and was not on the oral contraceptive pill. Clinically she was not jaundiced or pale and had no lymphadenopathy. The abdomen was tender to deep palpation in the right upper quadrant but no guarding or rigidity. Routine blood investigations revealed no leukocytosis, and liver function test was normal. Ultrasound examination revealed slightly thickened gall bladder wall with no pericholecystic fluid. The gall bladder contained multiple gallstones, and common bile duct was normal in size. She was diagnosed as biliary colic, settled on conservative treatment and was discharged 2 days later. She was readmitted as an emergency a week later with severe right upper quadrant pain, which radiated to the back. She underwent an uneventful laparoscopic cholecystectomy of an apparently normal gall bladder and was discharged home a day later. Histopathology of the gall bladder showed thickened gall bladder wall by fibrosis, edema and hemorrhage. There was mildly acute and chronic inflammatory infiltrate. The wall showed an area of aberrant pancreatic tissue with well-formed acini, ducts and islets (Figure 1). Aberrant pancreatic tissue or heterotopic pancreas is believed to occur because of pancreatic mass fragmentation during gastrointestinal tract rotation in the embryonic stage.4 Microscopically, it may resemble a complete pancreas structure (acini, duct and Langerhans islets) or without the islets. If found, components may be seen in all layers of the gastrointestinal tract.4 In our case, acini, ducts and islets were present (Figure 1). Histological analysis of 32 cases of heterotopic pancreas, all showed pancreatic excretory ducts; exocrine glands Clinical Notes