Gastrointestinal bleeding from jejunal heterotopic pancreas diagnosed by deep small-bowel enteroscopy.

A 70-year-old man presented with a 2-week history of overt (melena) and obscure gastrointestinal bleeding requiring an 8-unit blood transfusion. He underwent upper gastrointestinal endoscopy, colonoscopy, and push enteroscopy, all of which were nondiagnostic. A video capsule endoscopy, which reached the cecum at 6 hours and 21 minutes, showed active bleeding at 2 hours and 18 minutes without an obvious underlying lesion. The patient was transferred to our facility and underwent antegrade deep (spiral) enteroscopy. A medium-sized subepithelial mass with mucosal nodularity was found 90cm distal to the ligament of Treitz (●" Fig.1). Standard forceps biopsies were diagnostic of heterotopic pancreas. At laparoscopy, the tumor was easily identified at the site of the endoscopically placed tattoo (●" Fig.2) and jejunal resection was subsequently performed. Pathologic evaluation of the surgical specimen confirmed heterotopic pancreas (●" Fig.3a) with focal areas of mucosal ulceration (●" Fig.3b). Postoperatively, the patient did well and he had no recurrent bleeding at his 1-month follow-up visit. Heterotopic (ectopic) pancreas is a relatively rare submucosal tumor that occurs most commonly in the stomach and duodenum [1]. Most tumors are discovered incidentally during radiographic or endoscopic examination, but a small proportion of patients with heterotopic pancreas can present with symptoms such as abdominal pain or bleeding [2]. A few recent Fig.2 Laparoscopic view of the jejunal mass with the adjacent tattoo mark clearly visible.