Gastrointest Radiol 2, 123- 124 (1977) Gastrointestinal

Radiology �9 by Springer-Verlag 1977

Polypoid Gastric Heterotopia Causing Small Bowel Intussusception

Renato Santos and John S. Wills Department of Radiology, Wilmington Medical Center, Wilmington, Delaware, USA

Abstract. A case of polypoid heterotopic gastric mu- cosa in the jejunum presenting as intussusception is presented and the pertinent literature is reviewed.

Key words: Heterotopia, gastric Intussusception, small bowel.

Heterotopic gastric mucosa in the small bowel, other than in a Meckel's diverticulum or in association with other congenital bowel anomalies, is rare. To date, 19 cases have been reported in the literature. To our

knowledge none has been reported in the radiologic literature. It is the purpose of this paper to present an additional case and to review the literature on this subject.

Case Report

D. C. is a 32-year-old white male who presented with a history of dyspepsia for about three weeks. During this period, he was afraid to eat because of production of gas and abdominal disten- tion, and consequently lost about 14 pounds. He denied any nausea or abdominal pain but did experience some vomiting. Past and family history were non-contributory. Physical examination was

Fig. 1. A Contrast examination of small bowel showing an intus- susception in the jejunum in the region of the ligament of Treitz. B Spot film showing polypoid mass in the jejunum

Address" reprint requests to." John S. Wills, M.D., Department of Radiology, Wilmington Medical Center, Box 1668, Wilmington, DE 19899, USA

124 R. Santos and J.S. Wills: Polypoid Gastric Heterotopia

Fig. 2. A Low power magnification showing the resected polypoid mass. B High power magnification showing characteristic gastric glands and mucosal glands

unremarkable except for the presence of an appendectomy scar. Laboratory examinations were all within normal limits.

Upper gastrointestinal series showed an intussusception in the jejunum in the region of the ligament of Treitz (Fig. IA) with the suggestion of a polypoid mass (Fig. 1 B).

At laparatomy, a pedunculated polypoid mass measuring about 8.5 x 1.5 cm was resected from the proximal jejunum close to the ligament of Treitz.

Microscopic section of the resected polypoid mass revealed gastric type mucosa with gastric parietal cells and abundant mucous glands (Fig. 2).

Discussion

There are two theories regarding the origin of ectopic gastric mucosa in the small bowel: (l) that it repre- sents a congenital anomaly or (2) that it is the result of metaplasia from existing or neoplastic epithelium. Nicholson [1] theorized that the lesion was a result of metaplasia from existing intestinal epithelium. Tay- lor [2], in reporting 81 cases of all types of epithelial heterotopia of the alimentary tract, divided them into two types: a congenital and an acquired type, the latter considered to arise by metaplasia. Kimpton and Crane [3] thought these lesions were embryonic ano- malies but suggested pluripotentiality of intestinal epi- thelium that may manifest after birth. Gore and Wil- liams [4] suggested that they may represent metaplasia and hyperplasia in existing adenomatous polyps. Soule and Hallenbeck [5] in reporting four additional cases stated that the presence of three types of special- ized cells of the gastric mucosa in all their cases pre- cludes origin from metaplasia of existing intestinal

mucosa; they postulated that these lesions represent ectopic hamartomas or 'choristomas' . They further pointed out that when the relative frequency of ecto- pic gastric mucosa in small bowel diverticula and duplication is considered, it is not surprising that ecto- pic gastric mucosa should occur occasionally in an otherwise unaltered segment of small intestine.

References

1. Nicholson GW : Heteromorphoses (metaplasia) of the alimentary tract. J Pathol 26:399~,17, 1923

2. Taylor AL: The epithelial heterotopias of the alimentary tract, J Pathol 30:415~,49, 1927

3. Kimpton AR, Crane AR: Heterotopic gastric mucosa. N Engl J Med 218:627429, 1938

4. Gore I, Williams W J: AdenQmatous polyp of the jejunum com- posed of gastric mucosa. Cancer 6:164 166, 1953

5. Soule EH, HaUenbeck GA: Polypoid gastric heterotopia of the jejunum and ileum causing subacute intestinal obstruction. Surg Gynecol Obstet 108:282 288, 1959

6. Lee SM, Mosenthal WT, Weismann RE: Tumorous heterotopic gastric mucosa in the small intestine. Arch Surg 100:619422, 1970

7. Katsube Y, Lebhan NF, Noto AC, Hughes W: Heterotopic gastric mucosa of the ileum causing acute intussusception. Conn Med 38: 156-158, 1974

8. Nawaz K, Graham DY, Fechner RE, Eiband JM: Gastric het- erotopia in the ileum with ulceration and chronic bleeding. Gas- troenterology 66:113 117, 1974

9. Doberneck RC, Deane WM, Antoine JE: Ectopic gastric mucosa in the ileum: A cause of intussusception. J Pediatr Surg 11:99 100, 1976

Received: May 23, 1977; accepted: June 2, 1977