A Rare Case of the Jejunal Ectopic Pancreas Observed With an Endoscope

CASE REPORT A 69-year-old man hospitalized with chronic renal failure was introduced to our department to scrutinize the cause of anemia and black stool. The source of bleeding could not be identified with esophagogastroduodenoscopy and colonoscopy. Since blood was observed in the jejunum on capsule endoscopy, double-balloon enteroscopy was performed, which revealed a small bleeding ulcer at 40 cm distal from the ligament of Treitz, and hemostatic treatment was performed. At this procedure, a 20-mm elevated lesion that looked like a submucosal tumor was observed at 20 cm distal from the ligament of Treitz (Figure 1). The lesion was slightly faded and had a dimpling on the top, from which serous liquid was discharged (Figure 1). We biopsied the lesion using standard biopsy forceps for colonoscopy (Radial Jaw4 Standard Capacity; Boston Scientific, Marlborough, MA). Histological findings confirmed acinar tissue on the submucosa, which was positive for chymotrypsin staining, and the lesion was diagnosed as a jejunal ectopic pancreas (Figure 2). At present, the patient remains free of their original symptoms.Figure 1.: (A) Enteroscopy showed a 20-mm elevated lesion that looked like a submucosal tumor on 20 cm distal from the ligament of Treitz. (B) Observing closely with an endoscope, the lesion was slightly faded and had a dimpling on the top (indicated by an arrow), from which serous liquid was discharged.Figure 2.: (A) A biopsy confirmed acinar tissue on the submucosa. (B) The acinar tissue was positive for chymotrypsin staining.The ectopic pancreas is defined as the presence, outside its usual location, of pancreatic tissue that lacks anatomical and vascular continuity with the pancreas proper. Most ectopic pancreas are asymptomatic but can cause gastrointestinal obstruction and bleeding. The ectopic pancreas is often found incidentally during abdominal surgery or necropsy examination,1 the proportion of which has been reported to be 0.2% on abdominal surgery and 1%–14% on necropsy examination.2 Ectopic pancreatic tissue frequently occurs in the stomach (26.5%), duodenum (30.3%), and jejunum (16.3%).2 The jejunal ectopic pancreas found by endoscopy is very rare. It often occurs in the submucosa of the gastrointestinal wall, and endoscopic findings present with a submucosal tumor-like morphology, often with depressions and openings on the surface.3 In this case, typical endoscopic findings were recognized, and the serous fluid discharged from the opening was considered to be pancreatic juice. At present, there are no evidence-based guidelines for the management of the ectopic pancreas. The pancreatic juice may have formed the bleeding ulcer. Accordingly, local excision by partial resection of the small intestine or endoscopic mucosal resection with enteroscopy should be performed if the bleeding ulcer recurs. We report this rare case in which the jejunal ectopic pancreas could be observed in detail with an endoscope. DISCLOSURES Author contributions: All authors contributed equally to this manuscript. T. Yamada is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.