# Jejunal Polyps out of Place: A Case of Gastric Heterotopia of the Jejunum

Authors: Siri A. Urquhart; Nayantara Coelho-Prabhu
Journal: Case Reports in Gastrointestinal Medicine
 (2020)

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## Abstract

Heterotopia is the presence of normal physiologic tissue in an atypical location. Gastric heterotopia has been described in various locations throughout the gastrointestinal tract, including the small intestine. Gastric heterotopia of the small intestine typically is asymptomatic but may present in several ways with symptoms of obstruction, bleeding, perforation, intussusception, or pain. However, gastric heterotopia is rare beyond the duodenum except for its frequent association with Meckel’s diverticulum. This entity should be considered in the differential diagnosis of polypoid lesions presenting with symptoms of bleeding or obstruction especially in younger patients. We present a case of gastric heterotopia of the jejunum in a patient with a prior history of Meckel’s diverticulectomy after he presented with obstructive symptoms. His symptoms improved following resection of two jejunal polyps via antegrade double-balloon assisted enteroscopy with fluoroscopy. On histopathlogical examination, findings were consistent with gastric heterotopia. This case highlights the importance of considering gastric heterotopia in the differential diagnosis of polypoid lesions located beyond the ligament of Treitz in younger patients presenting with obstructive symptoms.


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## Body

## 1. Introduction

Heterotopia is the presence of mature physiologic tissue in an atypical location. Gastric heterotopia has been described in several locations throughout the gastrointestinal tract such as the esophagus, duodenum, gallbladder, Meckel’s diverticulum, and other areas within the small bowel and rectum. Gastric heterotopia of the small intestine can be asymptomatic or present in various ways with symptoms of obstruction, ulceration or bleeding, perforation, intussusception, or pain [1]. Gastric heterotopia beyond the ligament of Treitz is rare but should be considered in the differential diagnosis of polypoid lesions in young patients presenting with gastrointestinal bleeding or symptoms of obstruction [2].


## 2. Case Presentation

A 33-year-old gentleman presented with lower abdominal pain, occasional nausea, emesis, and inability to pass stool or flatus. He did not have any fever or chills. His past medical history was notable for Meckel’s diverticulectomy secondary to gastrointestinal bleeding which ultimately required ileal resection and stapled anastomosis ten years previously. The pathology following operative intervention did not demonstrate any ectopic gastric mucosa. He did not have any additional pertinent past medical, family, or social history.His vital signs were within normal limits. Physical examination was notable for a minimally distended abdomen with tympany on percussion. Laboratory investigations were unremarkable. Coronal and axial computed tomography enterography of the abdomen and pelvis with contrast (Figure1) demonstrated a 0.8 cm jejunal polyp in the proximal jejunum just past the ligament of Treitz. He subsequently underwent an antegrade double-balloon assisted enteroscopy with fluoroscopy which revealed a 1.5 cm semisessile polyp without bleeding at the ligament of Treitz in addition to a 0.7 cm sessile polyp in the proximal jejunum (Figure 2) which were then resected. Histopathology demonstrated nodular areas of gastric fundic heterotopia without dysplasia. Oxyntic glands with chief cells (arrows) and parietal cells (asterisks) are shown at high magnification (Figure 3). A diagnosis of gastric heterotopia of the jejunum was made. Following endoscopic resection, the patient was advised to avoid aspirin or nonsteroidal anti-inflammatory medications and to monitor hemoglobin annually for anemia.Figure 1
Coronal (a) and axial (b) computed tomography enterography of the abdomen and pelvis with contrast demonstrating a 0.8 cm jejunal polyp in the proximal jejunum just past the ligament of Treitz.
(a)(b)Figure 2
Antegrade double-balloon assisted enteroscopy with fluoroscopy demonstrating a semisessile polyp without bleeding at the ligament of Treitz.Figure 3
Histopathology with nodular areas of gastric fundic heterotopia without dysplasia. Oxyntic glands with chief cells (arrows) and parietal cells (asterisks) are shown at high magnification.


## 3. Discussion

Heterotopia is defined as the presence of normal physiologic tissue in an anatomic location where it is not normally found. Gastric heterotopia is not an uncommon lesion and can be found in several areas throughout the gastrointestinal tract. However, gastric heterotopia is rare beyond the duodenum except for its frequent association with Meckel’s diverticulum [3]. Gastric heterotopia of the small intestine may be asymptomatic or present with symptoms of intestinal obstruction, ulceration or bleeding, perforation, intussusception, or pain [1]. Gross appearance is characteristically a mucosal nodularity or polypoid lesion [2, 4]. Peptic ulceration in the area of heterotopia followed by inflammation and fibrosis may result in the formation of a stricture. Polyps can cause intussusception. On microscopic examination, the surface is lined by gastric foveolar epithelium with gastric glands, typically with fundic type mucosa [2].It is important to differentiate gastric heterotopia from gastric metaplasia. Gastric metaplasia is an acquired lesion and is usually seen in association with chronic inflammatory conditions such as inflammatory bowel disease. Unlike heterotopia which is a macroscopic lesion seen on radiographic imaging or endoscopy, ultimately requiring confirmation by biopsy, metaplasia is a microscopic lesion [2].The typical treatment for gastric heterotopia includes endoscopic or surgical resection to prevent complications. This case is unique in that the patient had two foci of gastric tissue outside of the stomach with a prior history of Meckel’s diverticulectomy and prior pathology at the time of small bowel resection without any evidence of ectopic gastric mucosa.It is important to recognize the variety of presentations associated with gastric heterotopia. A timely diagnosis of an enlarged polyp can prevent complications such as obstruction, intussusception, bleeding, or perforation. The combination of clinical presentation, radiologic imaging, and endoscopic and pathologic evaluation is helpful in making the diagnosis [5].In most reported cases of gastric heterotopia involving the jejunum (Table1), patients had a median age of 21.5 years with the youngest patient being one-year-old [6]. Presenting symptoms consisted of gastrointestinal bleeding [7–9] or obstructive symptoms as a result of a polypoid mass [1, 5, 10–17] and stricture [2, 3, 6]. One case report described a 16-year-old patient who developed perforation and ulceration involving the jejunum in the setting of gastric heterotopia [18]. One case report described a 21-year-old patient with a 15 cm intraluminal polypoid mass involving the jejunum [15], while two case reports described multiple strictures associated with jejunal gastric heterotopia [2, 6]. Gastric heterotopia was not suspected clinically in any of these cases and was diagnosed on histopathological examination.Table 1
Summary of previously reported cases of gastric heterotopia of the jejunum.
AuthorAgeSexPresenting features and diagnosisDurationGross appearanceSizeTreatmentAhn, et al. [10]5FVomiting, abdominal pain; diagnosed with intussusception of proximal jejunal loops2 weeksPolypoid lesions with erosions on the proximal jejunumVariable-sized with largest nearly obstructing jejunal lumenEndoscopic resectionAli, et al. [7]23MMelena, nausea, and vomitingUnknownJejunal diverticulum with white mucosal plaques 50 cm from pylorusUnknownMidline laparotomy and endoscopic wedge resectionAl-Jaadan, et al. [6]1FEpisodic abdominal distension, vomiting, diarrhea, and failure to thrive3 yearsDilated segment of proximal jejunum followed by 8 cm narrowed segment with thickened walls38 cm dilated segment of proximal jejunumLaparotomy with en-bloc small bowel resectionBhattacharya, et al. [1]52FIntermittent cramping, abdominal pain, and vomitingUnknownMucosal, broad-based, polypoid mass4 × 2.7 × 0.4 cmExploratory laparotomy with partial resection of jejunumChinnery, et al. [3]17FPostprandial vomiting and weight loss3 monthsJejunal stricture 15 cm distal to ligament of Treitz2 cm in lengthSurgical excisionIsbister, et al. [18]16FAbdominal pain and vomiting1 weekPerforation and ulcer involving the jejunum, 25 cm from duodenojejunal flexure2.5 cm in diameterLaparotomy with surgical resectionJimenez, et al. [8]4MAbdominal pain and melena3 daysLarge polypoid mass occupying 50% of the lumen9 × 4 cmLaparotomy with en-bloc small bowel resectionKhan, et al. [11]36FAbdominal pain and vomitingUnknownPolypoid lesion2 cmLaparoscopic resectionKimpton, et al. [12]7FEpisodic abdominal pain, nausea, and vomiting, and intussusception4 yearsTumor mass filling the entire lumen of the jejunum3 cm in diameterSurgical resectionLee, et al. [13]25MPostprandial abdominal pain and vomiting3 weeksElongated, serpiginous mucosal tumors8 × 3 cm and 6 × 3 cmSurgical resectionLeng, et al. [9]9FGastrointestinal bleeding with melena and mild anemia15 monthsPolypoid mass4 cmLaparoscopic resectionMandrekar, et al. [14]22FIntestinal obstructionUnknownPolypoidal mass8 × 6 × 2 cmEmergency laparotomy and resectionMartinez, et al. [15]21FIntermittent abdominal pain, nausea, and vomiting1 yearLarge intraluminal tumor of the jejunum15 cmAbdominal laparotomy with resectionNasir, et al. [5]31MPostprandial abdominal pain and hematochezia10 yearsPolypoid mass at duodenojejunal junction6 × 2.5 cmEndoscopic resectionNwanze, et al. [16]24FAbdominal pain, nausea and vomiting, and intussusception12 hoursProtruding polypoid mass of the jejunum3.4 × 2.7 × 2.4 cmEmergent surgical resectionOmotosho, et al. [17]17FRefluxlike symptoms, abdominal pain, vomiting, and intussusception6 monthsBilobed intraluminal jejunal polypUnknownSurgical resectionVani, et al. [2]24MAbdominal pain and peritonitisUnknownJejunal strictures and perforation40 cm of jejunum with multiple strictures and serosal exudateEmergent exploratory laparotomy and resectionGastric heterotopia can present in various ways including masslike lesions with symptoms of obstruction, pain, or bleeding, or may even remain asymptomatic. Gastric heterotopia beyond the ligament of Treitz is a rare entity. This case highlights the importance of considering gastric heterotopia in the differential diagnosis of polypoid lesions located beyond the ligament of Treitz in younger patients presenting with obstructive symptoms [2].



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