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Recurrent Ileoileal Intussusception Caused by Pedunculated Cystic Polyp Containing Heterotropic Pancreatic Tissue
AH Bhandarwar*, Waqar Ahmed Ansari**+
Abstract
A 20 year old male presented in emergency with acute onset abdominal pain, mild distension of abdomen in central part, 2-3 episodes of vomiting and constipation of one day duration. There was no h/o obstipation. There was no h/o bleeding/mucus per rectum. On general examination, patient has tachycardia, with normal BP, and no fever. Plain X-ray, showed few air fluid levels of terminal ileum. HB, CBC, was normal. No sign of toxaemia. Patient was diagnosed as subacute intestinal obstruction and was managed with conservative line of management and was advised to get barium meal follow through done to ascertain the cause of obstruction. Mantoux test was negative. While patient was waiting for barium meal follow through, he again developed similar complain but severity was more. This time decision to explore the patient was taken. On exploratory laparotomy, intussusception of terminal ileum was present and the cause of intussusception was approximately 6 x 3 x 3 cm large oval shaped pendunculated cystic poly with stalk of approximately 12-15 cms. Resection and anastomosis of ileal segment was done. Histopathology of the polyp wall came as heterotropic pancreatic tissue..
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Introduction
Intussusception occurs when one portion of
gut becomes invaginated within an immediately adjacent segment, invariably, it is proximal into distal bowel. Majority of acute intussusceptions are seen in children and only 10% seen in adult age group. In constrast to children, adults usually have a demonstrable cause of intussusception in more than 90% of times. Adult cases are invariably associated with a lead point which in usually a polyp, submucosal lipoma, or a tumour, the exception being after periods of prolonged fasting.
Heterotropic pancreas can be the cause of intussusception by forming a lead point. Heterotropic pancreas can occur from stomach (most common) to jejunum, ileum (least common). It can occur even at the hilum of spleen or in 2% of carefully conducted necropsies, within the liver.1 Intussusception caused by heterotropic pancreas is exceptionally rare.
Usually heterotropic pancreas is found in submucosa as a sessile polyp, when it is more than 1.5 cm in size, it can cause symptoms such as intussusception, bleeding etc.
Here we present a case of recurrent small bowel obstruction due to large pedunculated (12-15 cm) cystic polyp containing heterotropic pancreatic tissue, in which it is one of the rarest form of heterotropic pancreas.
Case Report
A 20 year old male presented in emergency with acute onset central abdominal pain, Colicky in nature, with mild distension of abdomen in central part, associated with 2-3 episodes of vomiting of one day duration, h/o constipation was present but there was no h/o obstipation. No h/o passage of blood and mucus in stool. There was no h/o tuberculosis, whether pulmonary or abdominal. No h/o evening rise of temperature of long duration, weight loss, anorexia or night sweat. No h/o passage of worms per rectally. On general examination, patient has pulse rate of 96/min, BP was normal. Per abdomen distension was present without any guarding, rigidity or rebound tenderness. Per rectal examination was normal, CBC - Normal, X-ray abdomen showed two air fluid levels in terminal ileum. Patient was diagnosed as subacute intestinal obstruction and was managed conservatively. After 12 hrs of conservative management, patient responded well. Patient was discharged from hospital after 4 days of conservative line of management and was advised to get Bariam meal follow through done.
While patient was waiting for his Bariam meal follow through to be done, he developed again similar complain but severity was more and came in emergency. This time per abdominal examination showed distended abdomen with no guarding, rigidity or rebound tenderness. Hyperperistalsis was present. Evidence of lumpish feel just lateral and inferior to umbilicus on right side was present.
USG abdomen was done, which suspected ileoileal intussusception and it was confirmed by plain abdominal CT Scan.
Patient was subjected to exploratory laparotomy. On opening the abdomen, evidence of ileoileal intussusception was present. Distal to the apex of intussusception, 6 x 3 x 3 cm oval mass was present, which was attached to the mucosa of terminal ileum proximally by a 12-15 cm narrow stalk. This attachment was the lead point of intussusception. Resection and anastomosis of ileum was done. The oval mass on opening was a cystic mass.
The histopathology of the wall of cystic mass showed pancreatic tissue, confirming heterotropic pancreas in terminal ileum.
Discussion
Intussusception is primarily a disease of children with only 5% of cases occurring in adults.1 In children, cause of intussusceptions is invariably idiopathic. In 90% of adult Intussusceptions, a cause can be found.
Among various causes of Intussusception, heterotropic pancreatic tissue is one of the rare cause of intussuseception. Klob first described the histological appearance of heterotropic pancreas in 1859.3 Lesions of more than 1.5 cm are clinically significant causing intussusception.4 In one study almost 44% the heterotropic pancreatic tissue was symptomatic, whereas in 56%, it was an incidental finding.5 Symptoms were related to complications, including obstruction of common bile duct, mucosal ulcer with haemorrhage, intussusception and intestinal obstruction but not to pathologic conditions of pancreas itself, such as pancreatitis or pancreatic cyst or neoplasm. In almost all clinically significant cases, the symptoms disappear completely after surgical removal of aberrant tissue.
The embryological derivation of heterotropic pancreas is well described. The pancreas in formed from several primitive endodermal evaginations of the primitive duodenal wall. The dorsal diverticulum becomes the body and tail and the ventral portion, the head of pancreas. If one or more of these evaginations remain within the wall of bowel then these can be carried as longitudial growth of the intestine continues, leading to ectopic tissue anywhere from stomach (most common) to jejunum or ileum (least common).
Although there are many reports of heterotropic pancreatic tissue causing intussusception, our case is different in that, it was a long pedunculated cystic polyp. Usually heterotropic pancreatic tissue is present in submucosa without any stalk (i.e. sessile polyp) and when it is more than 1.5 cm it becomes clinically significant.
References
1. Russel, Williams, Bulstrode, Bailey and Love’s : Short practice of surgery, 24th edition chap. 66, 1120.
2. Ponka JL. Intussusception in infants and adults. Surg Gynaecol Obstet 1967; 124 : 99-105.
3. Klob J. Pancrease accessorium, Zeitschrift der Kaiseri, Konigl. Gesellschaft der Aerzte zu Wien 1859; 15 : 732.
4. Armstrong CP, King PM, Dixon JM, Macleod IB. The clinical significance of heterotopic pancreas in the gastrointestinal tract. Br J Surg 1981; 68 : 384-7. (More details).
5. Pang LC. Panereatic heterotropia : a reappraisal and clinicopathologic analysis of 32 cases. South Med J 1988; 81 (10) : 1264-75.
6. Copleman B. Aberrant pancreas in the gastric wall. Radiology 1963; 81 : 107-11.
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| Fig. 1 : Resected specimen of ileoileal intussusception. |
Fig. 2 : Cystic polyp containing heterotropic pancreatic tissue.. |
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ATOPY EARLY IN LIFE AND CHRONIC ASTHMA IN CHILDREN
The chronic course of asthma...is determined by continuing allergic airway inflammation beginning in the first 3 years of life’
Reduced lung function is a feature of chronic asthma, but unknown factors between birth and school age determine the progressive loss of pulmonary function in children with persistent asthma. Sabina Illi and colleagues did a birth cohort study, following 1314 children in Germany to record details about the children’s asthma, IgE levels, allergen exposure, and lung function. The authors show that most children with wheeze without atopy lost their symptoms by school age and had normal lung function at puberty. However, children who had atopic sensitisation by the age of 3 years were likely to have loss of lung function at school age.
Lancet, 2006; 763. |
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