Jejunal Ectopic Pancreas Causing Gastric Outlet Obstruction

Jejunal Ectopic Pancreas Causing Gastric Outlet Obstruction | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Jejunal Ectopic Pancreas Causing Gastric Outlet Obstruction Rajendra Patel, Moksha Prasoona Avvaru, Suhas Kataveni This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7557191/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Ectopic pancreas (EP) is a rare congenital anomaly where pancreatic tissue is found outside the pancreas without any ductal or vascular connection. It is commonly located in the stomach but can also occur in the jejunum, ileum, liver, spleen, and other sites. EP is usually asymptomatic but can cause complications like inflammation, obstruction, or malignant transformation. This case report presents a patient with Ectopic Pancreas in the proximal jejunum, leading to gastric outlet obstruction. The patient had chronic abdominal pain and weight loss. Initial investigations, including endoscopic biopsies, were inconclusive, but contrast-enhanced CT suggested EP. Surgical intervention was performed due to persistent symptoms, revealing a contained jejunal perforation. Histopathology confirmed the Ectopic Pancreas and the patient recovered well postoperatively. This case highlights the diagnostic challenges of the Ectopic Pancreas. While imaging aids in diagnosis, histopathology remains the gold standard. Awareness of the ectopic Pancreas as a rare cause of gastric outlet obstruction is crucial for timely management. Gastroenterology & Hepatology Internal Medicine Gastrointestinal Surgery Ectopic pancreas Heterotopic pancreas Jejunal mass Gastric outlet obstruction Submucosal lesion Small bowel obstruction Abdominal pain Intestinal perforation Histopathology Case report Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure 10 Figure 11 Figure 12 Figure 13 Figure 14 LEARNING POINTS Ectopic pancreas as gastric outlet obstruction is a rare presentation. Submucosal lesions can be ruled out with the help of cross-sectional imaging and EUS-guided FNAC. Histology is a gold standard for diagnosis in cases of a diagnostic dilemma, exploratory laparotomy with biopsy can help in establishing diagnosis. BACKGROUND The first case of ectopic pancreas (EP) (also referred to as heterotopic pancreas, pancreatic heterotopia, accessory pancreas, aberrant pancreas, or pancreatic rest) was described in 1727 when it was identified in the ileal diverticulum [ 1 ]. Ectopic pancreas is a rare congenital anomaly, which is due to the development of the pancreatic tissue outside the pancreas without any ductal or vascular connection to the main pancreatic tissue [ 2 ]. The ectopic pancreas is commonly seen in the stomach (30–50%), it is comparatively less prevalent in the jejunum, with a reported frequency of only 13% [ 3 ]. There are other locations where EP has been identified which are the ileum, liver, spleen, biliary tract, mesentery, Meckel’s diverticulum, fallopian tubes, or umbilicus [ 4 ]. The incidence of EP on the autopsy specimens is around 0.5%-13.7% with male predominance [ 5 ]. It is mostly located in the submucosa but rarely in the muscularis or serosa. The ectopic pancreas is usually a silent anomaly, but it may become symptomatic when complicated by pathologic changes such as inflammation, bleeding, obstruction, or malignant transformation [ 6 7 8 ]. Different theories have been told behind the development of EP. According to one theory, duodenal evagination persists after the development of normal pancreatic tissue [ 8 ]. This evagination then separates from the actual pancreatic tissue and migrates along the developing gastrointestinal tract, which could explain the different locations of EP. Another theory suggests pancreatic metaplasia of the endodermal tissues in the gastric mucosa, which could explain the location of EP in the stomach [ 9 ]. CASE PRESENTATION A man in his mid-30s presented to OPD with complaints of intermittent abdominal pain that worsened with food intake. The pain was accompanied by episodes of bilious vomiting and persistent constipation for the past week. He also reported unintentional weight loss of approximately 8 kgs over the last three months. Upon further inquiry, the patient revealed that he had been experiencing similar but milder episodes of abdominal discomfort and altered bowel habits intermittently over the past year. These episodes were managed conservatively by a local physician with oral medications, providing only temporary relief. However, he denied experiencing fever, jaundice, or shortness of breath. His medical history was unremarkable, with no known comorbidities, prior surgeries, inflammatory bowel disease, or tuberculosis infection. There was no significant family history of gastrointestinal disorders, malignancies, or metabolic conditions. Additionally, he did not report any substance use or addictions. On physical examination, mild tenderness was noted in the epigastric region, but there were no signs of guarding rigidity, or palpable masses. Bowel sounds were present, and no venous hum or arterial bruits were detected. INVESTIGATIONS Routine laboratory investigations revealed a haemoglobin level of 11.6 gm/dL with a reduced haematocrit of 36%. His erythrocyte sedimentation rate was significantly elevated at 69 mm/hr. However, his leukocyte count, platelet count, liver function tests, serum lipase, creatinine, and random blood sugar levels were all within normal limits. Notably, his serum amylase was mildly elevated at 143 U/L. An erect abdominal X-ray showed no abnormalities and viral markers were negative. An abdominal ultrasound was performed, revealing circumferential hypoechoic thickening of the small bowel in the left hypochondrium. Additionally, there was a hypoechoic collection or cyst–like lesion with adjacent inflammation, mesenteric fat stranding, and sub centimetre mesenteric lymph nodes. Given the patient’s persistent symptoms, a gastroduodenoscopy was conducted. The procedure revealed retained solid food within the stomach, along with a dilated duodenal lumen. Upon advancing the scope to the proximal jejunum, a circumferential nodular lesion causing luminal narrowing was identified . Biopsy samples from the lesion demonstrated mild active inflammation, and GeneXpert testing for tuberculosis was negative. To further evaluate the lesion, CT enterography was performed, which identified a moderately enhancing soft tissue mass in the proximal jejunum measuring approximately 4 x 1.5 cm. A central duct-like structure was observed within the lesion, accompanied by mesenteric fat stranding and a localized fluid collection (2.4 x 1.8 cm) within the proximal jejunal mesentery. Additional findings included bowel wall thickening and mildly enlarged mesenteric lymph nodes measuring up to 12 mm. To confirm these findings and rule out pancreatic involvement, a dedicated CT pancreatic protocol was performed (Figure 1-8). Given the diagnostic uncertainty and the patient’s worsening clinical condition, the case was reviewed in a multidisciplinary board meeting. After a thorough discussion, surgical management was deemed necessary, and the patient was admitted under the care of the surgical gastroenterology department for further intervention. DIFFERENTIAL DIAGNOSIS Initially, during the patient's evaluation in the outpatient department (OPD) following an abdominal ultrasound and gastroduodenoscopy, both inflammatory bowel disease and abdominal Koch's were considered as potential diagnoses. However, after cross-sectional imaging and a detailed discussion with the radiologist, the possibility of an ectopic pancreas causing subacute intestinal obstruction was raised. Other subepithelial lesions, including lipoma, GIST, lymphoma, NET, and leiomyoma, were also considered as differential diagnoses. TREATMENT After preoperative evaluation and optimization, the patient was taken up for surgery. Intraoperatively surgeons could find dilated duodenum and proximal jejunum and contained proximal jejunal perforation present with phlegmon extending to the base of mesentery. Because of suspicion of lymph nodal mass also keeping in mind the probability of Ectopic pancreas in imaging - Jejunal resection and anastomosis were done (stapled)(Figure 9,10). Feeding jejunostomy was done (Witzel technique). OUTCOME AND FOLLOW-UP Post-operative status has been uneventful with no history of fever or shortness of breath. The patient was later discharged from the hospital on Post Operative day – 8. Histology evaluation revealed a jejunal resection specimen measuring 34 cm in length, showing an exophytic mass measuring 3.8*4.2 cm along the mesenteric border. The microscopic examination showed unremarkable intestinal mucosa and submucosa showing benign pancreatic parenchyma with intervening ducts and islet cell clusters (Figure 11-14). The final impression was suggestive of ectopic pancreatic tissue in the submucosa of the jejunum extending up to the subserosa with 9 reactive lymph nodes. DISCUSSION Ectopic pancreas (EP) is majorly asymptomatic and only 50% of small bowel lesions show non-specific symptoms [ 10 ]. Symptoms and clinical picture of the patient vary from location and size of ectopic pancreas present [ 11 ]. EP is identified incidentally during the surgery performed for other indications in the majority of cases [ 5 ]. There were reports of rare cases showing evidence of malignancies developed from ectopic pancreas [ 12 ]. EP in jejunum is itself very rare and it always presents with complaints of pain abdomen and few cases of obstruction, GI bleeding, perforation, and peritonitis are observed. Our patient, presented with gastric outlet obstruction with a longer duration of history and associated weight loss. Diagnosis of EP is extremely difficult without histopathological examination but high clinical suspicion and cross-sectional imaging can help in management. Clinical history with elevated amylase and lipase along with contrast-enhanced CT imaging can point toward an Ectopic pancreas. In contrast, enhanced CT lesions are seen as round or oval lesions, ill-defined margins, and prominent enhancement of the overlying mucosa [ 13 ]. EP demonstrates a characteristic high signal intensity on T1-weighted magnetic resonance (MR) making it hard to differentiate EP from other lesions. The “ectopic duct” sign, a dilated EP duct, is a sensitive finding that could be appreciated on both T2-weighted MR and MRCP. The use of secretin during MRCP helps further improve the visualization of this sign [ 14 ]. The ectopic pancreas is usually small and may be missed by imaging and the degree of enhancement and homogeneity of the ectopic pancreas depends on its histologic composition. Acini-predominant ectopic pancreas has greater enhancement than the normal pancreas, whereas ductal predominant lesions show lower enhancement [ 15 ]. Lesions from imaging can still easily be misdiagnosed with other submucosal tumours. Lesions in the upper GI tract usually present as a mass covered by normal mucosa and protrude in the lumen [ 16 ]. Ectopic pancreatic tissue is typically located in the submucosa (76%), the muscular layer (15%), or the subserosa (9%) [ 11 ] for which EUS-guided biopsies help in tissue diagnosis. Therefore, endoscopically surface biopsies are rarely conclusive. Definitive diagnosis is only made by histopathological examination and is classified into three subtypes as described by Heinrich in 1909 [ 8 ]. Type 1 (most common) contains acini, pancreatic ducts, and islet cells; type 2 is composed of acini and pancreatic ducts without islet cells; type 3 has only pancreatic ducts. Type 4 was later added by Gasper in 1973 which contains only pancreatic islet cells on histological examination [ 8 ]. Since this patient had gastric outlet obstructive symptoms which is a common presentation, further evaluation with CT/MRI and endoscopic ultrasound with Fine needle aspiration can help in establishing a diagnosis where it differentiates other submucosal lesions. On endoscopic ultrasound, EP may appear as a solid submucosal mass of low echogenicity when compared to the hyperechoic submucosa, and isoechoic to the hypoechoic muscularis propria [ 14 ]. Initially based on symptoms and endoscopic appearance of stricture- Intestinal tuberculosis and Crohn’s disease were considered differential diagnoses. Since endoscopic biopsy were inconclusive and CT was showing findings suggestive of ectopic pancreas, surgical management was considered. From the surgeon’s perspective, intra-operative findings looked like contained perforation of proximal jejunum with suspected lymph node mass. Keeping in mind the likely diagnosis of the ectopic pancreas from imaging, jejunal resection, and anastomosis were done. Histology evaluation confirmed ectopic pancreas and the patient was asymptomatic on follow-up. This case report helps us understand ectopic pancreas presenting as a rare cause of gastric outlet obstruction. PATIENTS PERSPECTIVE At the onset of my illness, I struggled to identify the exact issue. It was a persistent unease that slowly intensified, leaving me anxious. Despite my concerns, I attempted to endure it, hoping it would resolve itself. However, when it persisted, I realized I needed a professional evaluation. Receiving the diagnosis was both comforting and startling. On one side, I was relieved to finally understand the cause of my symptoms, yet on the other, I was filled with apprehension. How would this affect my life? How would I manage? The medical team was excellent in explaining the diagnosis in a clear and non-overwhelming manner. Their compassion was significant, making me feel supported. The treatment journey was challenging, and I would be dishonest if I said I wasn’t frightened at times. There were moments of physical and emotional exhaustion. Nevertheless, the support from my family and the kindness of the healthcare staff sustained me. Their encouraging words and genuine care made the process more bearable. Recovery presented its own hurdles. There were highs and lows, but I focused on small achievements—days when I felt a bit stronger, instances when I accomplished something new. Each progress gave me hope. Reflecting now, I recognize my resilience, even when circumstances seemed uncontrollable. This experience has altered my perspective on health. It has taught me to heed my body’s signals and not dismiss early signs of potential issues. I am thankful for the medical team who guided me and for my loved ones who stood by me. By sharing my story, I hope to inspire others to prioritize their health and seek help when necessary. *The patient’s perspective was translated to English from patient’s original spoken language by Dr. Rajendra Patel. INTELLECTUAL PROPERTY RIGHTS ASSIGNMENT OR LICENCE STATEMENT I, SUHAS KATAVENI, the Author has the right to grant and does grant on behalf of all authors, an exclusive licence and/or a non-exclusive licence for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance with the relevant stated licence terms for US Federal Government Employees acting in the course of the their employment, on a worldwide basis to the BMJ Publishing Group Ltd (“BMJ”) and its licensees, to permit this Work (as defined in the below licence), if accepted, to be published in BMJ Case Reports and any other BMJ products and to exploit all rights, as set out in our licence author licence. Date: 30 TH MARCH, 2025. Declarations Consent Statement: Written informed consent was obtained from the patient for participation in this case study and for the publication of their clinical details. 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Pancreatic Heterotopia of the Duodenum: Anatomic Anomaly or Clinical Challenge? Journal of Gastrointestinal Surgery. 2011;15(4). doi:10.1007/s11605-011-1420-2 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7557191","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":511447528,"identity":"4605402d-cac3-4a7f-8d93-4328f50f24d8","order_by":0,"name":"Rajendra Patel","email":"","orcid":"","institution":"AIG Hospitals, Gachibowli, Hyderabad","correspondingAuthor":false,"prefix":"","firstName":"Rajendra","middleName":"","lastName":"Patel","suffix":""},{"id":511447529,"identity":"e6d2b44d-e642-4b82-ad43-3871ffb19596","order_by":1,"name":"Moksha Prasoona Avvaru","email":"","orcid":"","institution":"Cape Fear Valley Harnett 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12","display":"","copyAsset":false,"role":"figure","size":155432,"visible":true,"origin":"","legend":"\u003cp\u003eH+E-100* - Pancreatic parenchyma with intervening\u003c/p\u003e\n\u003cp\u003educts and islet cell clusters\u003c/p\u003e","description":"","filename":"Picture12.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7557191/v1/ac17a89f721595d5969f9ee2.jpg"},{"id":91077713,"identity":"faa58f99-0430-4b48-9897-8d29abef80a5","added_by":"auto","created_at":"2025-09-11 11:16:37","extension":"jpg","order_by":13,"title":"Figure 13","display":"","copyAsset":false,"role":"figure","size":220910,"visible":true,"origin":"","legend":"\u003cp\u003eH+E-400* - Islet cell clusters see in resected ectopic\u003c/p\u003e\n\u003cp\u003epancreatic tissue.\u003c/p\u003e","description":"","filename":"Picture13.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7557191/v1/8838aa2dcb4cd0c0f6e7705d.jpg"},{"id":91077712,"identity":"8c90234f-d458-4ec1-aafa-0635218e41c8","added_by":"auto","created_at":"2025-09-11 11:16:37","extension":"jpg","order_by":14,"title":"Figure 14","display":"","copyAsset":false,"role":"figure","size":230984,"visible":true,"origin":"","legend":"\u003cp\u003eH+E-400* -Pancreatic parenchyma with intervening\u003c/p\u003e\n\u003cp\u003educts and islet cell clusters.\u003c/p\u003e","description":"","filename":"Picture14.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7557191/v1/e424fdb6b24890fabc9aefe8.jpg"},{"id":91081605,"identity":"c3604e1b-15ae-4a4d-9d4f-afa45520d11c","added_by":"auto","created_at":"2025-09-11 11:40:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1358565,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7557191/v1/4ca60c68-63cb-4cd1-8933-11ba3384d0e8.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eJejunal Ectopic Pancreas Causing Gastric Outlet Obstruction\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"LEARNING POINTS","content":"\u003cul\u003e\n \u003cli\u003eEctopic pancreas as gastric outlet obstruction is a rare presentation.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eSubmucosal lesions can be ruled out with the help of cross-sectional imaging and EUS-guided FNAC.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eHistology is a gold standard for diagnosis in cases of a diagnostic dilemma, exploratory laparotomy with biopsy can help in establishing diagnosis.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"BACKGROUND","content":"\u003cp\u003eThe first case of ectopic pancreas (EP) (also referred to as heterotopic pancreas, pancreatic heterotopia, accessory pancreas, aberrant pancreas, or pancreatic rest) was described in 1727 when it was identified in the ileal diverticulum [\u003csup\u003e1\u003c/sup\u003e]. Ectopic pancreas is a rare congenital anomaly, which is due to the development of the pancreatic tissue outside the pancreas without any ductal or vascular connection to the main pancreatic tissue [\u003csup\u003e2\u003c/sup\u003e]. The ectopic pancreas is commonly seen in the stomach (30–50%), it is comparatively less prevalent in the jejunum, with a reported frequency of only 13% [\u003csup\u003e3\u003c/sup\u003e]. There are other locations where EP has been identified which are the ileum, liver, spleen, biliary tract, mesentery, Meckel’s diverticulum, fallopian tubes, or umbilicus [\u003csup\u003e4\u003c/sup\u003e].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe incidence of EP on the autopsy specimens is around 0.5%-13.7% with male predominance [\u003csup\u003e5\u003c/sup\u003e]. It is mostly located in the submucosa but rarely in the muscularis or serosa. The ectopic pancreas is usually a silent anomaly, but it may become symptomatic when complicated by pathologic changes such as inflammation, bleeding, obstruction, or malignant transformation [\u003csup\u003e6\u003c/sup\u003e \u003csup\u003e7\u003c/sup\u003e \u003csup\u003e8\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eDifferent theories have been told behind the development of EP. According to one theory, duodenal evagination persists after the development of normal pancreatic tissue [\u003csup\u003e8\u003c/sup\u003e]. This evagination then separates from the actual pancreatic tissue and migrates along the developing gastrointestinal tract, which could explain the different locations of EP. Another theory suggests pancreatic metaplasia of the endodermal tissues in the gastric mucosa, which could explain the location of EP in the stomach [\u003csup\u003e9\u003c/sup\u003e].\u003c/p\u003e"},{"header":"CASE PRESENTATION","content":"\u003cp\u003eA man in his mid-30s presented to OPD with complaints of intermittent abdominal pain that worsened with food intake. The pain was accompanied by episodes of bilious vomiting and persistent constipation for the past week. He also reported unintentional weight loss of approximately 8 kgs over the last three months.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUpon further inquiry, the patient revealed that he had been experiencing similar but milder episodes of abdominal discomfort and altered bowel habits intermittently over the past year. These episodes were managed conservatively by a local physician with oral medications, providing only temporary relief. However, he denied experiencing fever, jaundice, or shortness of breath. His medical history was unremarkable, with no known comorbidities, prior surgeries, inflammatory bowel disease, or tuberculosis infection. There was no significant family history of gastrointestinal disorders, malignancies, or metabolic conditions. Additionally, he did not report any substance use or addictions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOn physical examination, mild tenderness was noted in the epigastric region, but there were no signs of guarding rigidity, or palpable masses. Bowel sounds were present, and no venous hum or arterial bruits were detected.\u003c/p\u003e"},{"header":"INVESTIGATIONS","content":"\u003cp\u003eRoutine laboratory investigations revealed a haemoglobin level of 11.6 gm/dL with a reduced haematocrit of 36%. His erythrocyte sedimentation rate was significantly elevated at 69 mm/hr. However, his leukocyte count, platelet count, liver function tests, serum lipase, creatinine, and random blood sugar levels were all within normal limits. Notably, his serum amylase was mildly elevated at 143 U/L.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAn erect abdominal X-ray showed no abnormalities and viral markers were negative. An abdominal ultrasound was performed, revealing circumferential hypoechoic thickening of the small bowel in the left hypochondrium. Additionally, there was a hypoechoic collection or cyst\u0026ndash;like lesion with adjacent inflammation, mesenteric fat stranding, and sub centimetre mesenteric lymph nodes. Given the patient\u0026rsquo;s persistent symptoms, a gastroduodenoscopy was conducted. The procedure revealed retained solid food within the stomach, along with a dilated duodenal lumen. Upon advancing the scope to the proximal jejunum, a circumferential nodular lesion causing luminal narrowing was identified . Biopsy samples from the lesion demonstrated mild active inflammation, and GeneXpert testing for tuberculosis was negative.\u003c/p\u003e\n\u003cp\u003eTo further evaluate the lesion, CT enterography was performed, which identified a moderately enhancing soft tissue mass in the proximal jejunum measuring approximately 4 x 1.5 cm. A central duct-like structure was observed within the lesion, accompanied by mesenteric fat stranding and a localized fluid collection (2.4 x 1.8 cm) within the proximal jejunal mesentery. Additional findings included bowel wall thickening and mildly enlarged mesenteric lymph nodes measuring up to 12 mm. To confirm these findings and rule out pancreatic involvement, a dedicated CT pancreatic protocol was performed (Figure 1-8). Given the diagnostic uncertainty and the patient\u0026rsquo;s worsening clinical condition, the case was reviewed in a multidisciplinary board meeting. After a thorough discussion, surgical management was deemed necessary, and the patient was admitted under the care of the surgical gastroenterology department for further intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDIFFERENTIAL DIAGNOSIS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInitially, during the patient\u0026apos;s evaluation in the outpatient department (OPD) following an abdominal ultrasound and gastroduodenoscopy, both inflammatory bowel disease and abdominal Koch\u0026apos;s were considered as potential diagnoses. However, after cross-sectional imaging and a detailed discussion with the radiologist, the possibility of an ectopic pancreas causing subacute intestinal obstruction was raised. Other subepithelial lesions, including lipoma, GIST, lymphoma, NET, and leiomyoma, were also considered as differential diagnoses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTREATMENT\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter preoperative evaluation and optimization, the patient was taken up for surgery. Intraoperatively surgeons could find dilated duodenum and proximal jejunum and contained proximal jejunal perforation present with phlegmon extending to the base of mesentery. Because of suspicion of lymph nodal mass also keeping in mind the probability of Ectopic pancreas in imaging - Jejunal resection and anastomosis were done (stapled)(Figure 9,10). Feeding jejunostomy was done (Witzel technique).\u0026nbsp;\u003c/p\u003e"},{"header":"OUTCOME AND FOLLOW-UP","content":"\u003cp\u003ePost-operative status has been uneventful with no history of fever or shortness of breath. The patient was later discharged from the hospital on Post Operative day – 8. Histology evaluation revealed a jejunal resection specimen measuring 34 cm in length, showing an exophytic mass measuring 3.8*4.2 cm along the mesenteric border. The microscopic examination showed unremarkable intestinal mucosa and submucosa showing benign pancreatic parenchyma with intervening ducts and islet cell clusters (Figure 11-14). The final impression was suggestive of ectopic pancreatic tissue in the submucosa of the jejunum extending up to the subserosa with 9 reactive lymph nodes.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eEctopic pancreas (EP) is majorly asymptomatic and only\u0026nbsp;50% of small bowel lesions show non-specific symptoms [\u003csup\u003e10\u003c/sup\u003e].\u0026nbsp;Symptoms and clinical picture of the patient vary from location and size of ectopic pancreas present [\u003csup\u003e11\u003c/sup\u003e].\u0026nbsp;EP is identified incidentally during the surgery performed for other indications in the majority of cases [\u003csup\u003e5\u003c/sup\u003e]. There were reports of rare cases showing evidence of malignancies developed from ectopic pancreas [\u003csup\u003e12\u003c/sup\u003e]. EP in jejunum is itself very rare and it always presents with complaints of pain abdomen and few cases of obstruction, GI bleeding, perforation, and peritonitis are observed. Our patient, presented with gastric outlet obstruction with a longer duration of history and associated weight loss.\u003c/p\u003e\n\u003cp\u003eDiagnosis of EP is extremely difficult without histopathological examination but high clinical suspicion and cross-sectional imaging can help in management. Clinical history with elevated amylase and lipase along with contrast-enhanced CT imaging can point toward an Ectopic pancreas. In contrast, enhanced CT lesions are seen as round or oval lesions, ill-defined margins, and prominent enhancement of the overlying mucosa [\u003csup\u003e13\u003c/sup\u003e].\u0026nbsp;EP demonstrates a characteristic high signal intensity on T1-weighted magnetic resonance (MR) making it hard to differentiate EP from other lesions. The “ectopic duct” sign, a dilated EP duct, is a sensitive finding that could be appreciated on both T2-weighted MR and MRCP. The use of secretin during MRCP helps further improve the visualization of this sign [\u003csup\u003e14\u003c/sup\u003e].\u0026nbsp;The ectopic pancreas is usually small and may be missed by imaging and the degree of enhancement and homogeneity of the ectopic pancreas depends on its histologic composition. Acini-predominant ectopic pancreas has greater enhancement than the normal pancreas, whereas ductal predominant lesions show lower enhancement [\u003csup\u003e15\u003c/sup\u003e]. Lesions from imaging can still easily be misdiagnosed with other submucosal tumours.\u003c/p\u003e\n\u003cp\u003eLesions in the upper GI tract usually present as a mass covered by normal mucosa and protrude in the lumen [\u003csup\u003e16\u003c/sup\u003e]. Ectopic pancreatic tissue is typically located in the submucosa (76%), the muscular layer (15%), or the subserosa (9%) [\u003csup\u003e11\u003c/sup\u003e] for which EUS-guided biopsies help in tissue diagnosis. Therefore, endoscopically surface biopsies are rarely conclusive. Definitive diagnosis is only made by histopathological examination and is classified into three subtypes as described by Heinrich in 1909 [\u003csup\u003e8\u003c/sup\u003e]. Type 1 (most common) contains acini, pancreatic ducts, and islet cells; type 2 is composed of acini and pancreatic ducts without islet cells; type 3 has only pancreatic ducts. Type 4 was later added by Gasper in 1973 which contains only pancreatic islet cells on histological examination [\u003csup\u003e8\u003c/sup\u003e]. Since this patient had gastric outlet obstructive symptoms which is a common presentation, further evaluation with CT/MRI and endoscopic ultrasound with Fine needle aspiration can help in establishing a diagnosis where it differentiates other submucosal lesions. On endoscopic ultrasound, EP may appear as a solid submucosal mass of low echogenicity when compared to the hyperechoic submucosa, and isoechoic to the hypoechoic muscularis propria [\u003csup\u003e14\u003c/sup\u003e].\u003c/p\u003e\n\u003cp\u003eInitially based on symptoms and endoscopic appearance of stricture- Intestinal tuberculosis and Crohn’s disease were considered differential diagnoses. Since endoscopic biopsy were inconclusive and CT was showing findings suggestive of ectopic pancreas, surgical management was considered. From the surgeon’s perspective, intra-operative findings looked like contained perforation of proximal jejunum with suspected lymph node mass. Keeping in mind the likely diagnosis of the ectopic pancreas from imaging, jejunal resection, and anastomosis were done. Histology evaluation confirmed ectopic pancreas and the patient was asymptomatic on follow-up. This case report helps us understand ectopic pancreas presenting as a rare cause of gastric outlet obstruction.\u003c/p\u003e"},{"header":"PATIENTS PERSPECTIVE","content":"\u003cp\u003eAt the onset of my illness, I struggled to identify the exact issue. It was a persistent unease that slowly intensified, leaving me anxious. Despite my concerns, I attempted to endure it, hoping it would resolve itself. However, when it persisted, I realized I needed a professional evaluation. Receiving the diagnosis was both comforting and startling. On one side, I was relieved to finally understand the cause of my symptoms, yet on the other, I was filled with apprehension. How would this affect my life? How would I manage? The medical team was excellent in explaining the diagnosis in a clear and non-overwhelming manner. Their compassion was significant, making me feel supported. The treatment journey was challenging, and I would be dishonest if I said I wasn\u0026rsquo;t frightened at times. There were moments of physical and emotional exhaustion. Nevertheless, the support from my family and the kindness of the healthcare staff sustained me. Their encouraging words and genuine care made the process more bearable. Recovery presented its own hurdles. There were highs and lows, but I focused on small achievements\u0026mdash;days when I felt a bit stronger, instances when I accomplished something new. Each progress gave me hope. Reflecting now, I recognize my resilience, even when circumstances seemed uncontrollable. This experience has altered my perspective on health. It has taught me to heed my body\u0026rsquo;s signals and not dismiss early signs of potential issues. I am thankful for the medical team who guided me and for my loved ones who stood by me. By sharing my story, I hope to inspire others to prioritize their health and seek help when necessary.\u003c/p\u003e\n\u003cp\u003e*The patient\u0026rsquo;s perspective was translated to English from patient\u0026rsquo;s original spoken language by Dr. Rajendra Patel.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eINTELLECTUAL PROPERTY RIGHTS ASSIGNMENT OR LICENCE STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI, \u003cstrong\u003eSUHAS KATAVENI,\u0026nbsp;\u003c/strong\u003ethe Author has the right to grant and does grant on behalf of all authors, an exclusive licence and/or a non-exclusive licence for contributions from authors who are: i) UK Crown employees; ii) where BMJ has agreed a CC-BY licence shall apply, and/or iii) in accordance with the relevant stated licence terms for US Federal Government Employees acting in the course of the their employment, on a worldwide basis to the BMJ Publishing Group Ltd (\u0026ldquo;BMJ\u0026rdquo;) and its licensees, \u0026nbsp;to permit this Work \u0026nbsp;(as defined in the below licence), if accepted, to be published in BMJ Case Reports and any other BMJ products and to exploit all rights, as set out in our licence author licence.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDate: 30\u003csup\u003eTH\u003c/sup\u003e MARCH, 2025.\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eConsent Statement: Written informed consent was obtained from the patient for participation in this case study and for the publication of their clinical details.\u003c/p\u003e"},{"header":"REFERENCES","content":"\u003col\u003e\n\u003cli\u003eChristodoulidis G, Zacharoulis D, Barbanis S, Katsogridakis E, Hatzitheofilou K. Heterotopic pancreas in the stomach: A case report and literature review. World J Gastroenterol. 2007;13(45). doi:10.3748/wjg.13.6098\u003c/li\u003e\n\u003cli\u003eAmmar H, Said MA, Mizouni A, et al. Ectopic pancreas: A rare cause of occult gastrointestinal bleeding. Annals of Medicine and Surgery. 2020;59. doi:10.1016/j.amsu.2020.09.005\u003c/li\u003e\n\u003cli\u003eJun SY, Son D, Kim MJ, et al. Heterotopic pancreas of the gastrointestinal tract and associated precursor and cancerous lesions: Systematic pathologic studies of 165 cases. American Journal of Surgical Pathology. 2017;41(6). doi:10.1097/PAS.0000000000000850\u003c/li\u003e\n\u003cli\u003eAlqahtani A, Aljohani E, Almadi F, Billa S, Alqahtani M, Alkhaldi H. Heterotopic pancreatic tissue in the gastric antrum an incidental finding during bariatric surgery: A case report and literature review. Int J Surg Case Rep. 2020;67. doi:10.1016/j.ijscr.2019.12.040\u003c/li\u003e\n\u003cli\u003eMulholland KC, Wallace WD, Epanomeritakis E, Hall SR. Pseudocyst formation in gastric ectopic pancreas. Journal of the Pancreas. 2004;5(6).\u003c/li\u003e\n\u003cli\u003eChen HL, Lin SC, Chang WH, Yang TL, Chen YJ. Identification of ectopic pancreas in the ileum by capsule endoscopy. Journal of the Formosan Medical Association. 2007;106(3). doi:10.1016/S0929-6646(09)60246-1\u003c/li\u003e\n\u003cli\u003eHassan H. Heterotopic Pancreas: A Rare Cause of Ileo-Ileal Intussusception. Pol J Radiol. 2014;79:349-351. doi:10.12659/pjr.890913\u003c/li\u003e\n\u003cli\u003eTrifan A, T\u0026acirc;rcoveanu E, Danciu M, Huţanaşu C, Cojocariu C, Stanciu C. Gastric heterotopic pancreas: An unusual case and review of the literature. Journal of Gastrointestinal and Liver Diseases. 2012;21(2).\u003c/li\u003e\n\u003cli\u003eDhruv S, Polavarapu A, Asuzu I, Andrawes S, Mukherjee I. Jejunal Ectopic Pancreas: A Rare Cause of Small Intestinal Mass. Cureus. Published online 2021. doi:10.7759/cureus.15409\u003c/li\u003e\n\u003cli\u003eOrmarsson OT, Gudmundsdottir I, M\u0026aring;rvik R. Diagnosis and treatment of gastric heterotopic pancreas. In: World Journal of Surgery. Vol 30. ; 2006. doi:10.1007/s00268-005-0669-6\u003c/li\u003e\n\u003cli\u003eBetzler A, Mees ST, Pump J, et al. Clinical impact of duodenal pancreatic heterotopia - Is there a need for surgical treatment? BMC Surg. 2017;17(1). doi:10.1186/s12893-017-0250-x\u003c/li\u003e\n\u003cli\u003eZhang P, Wang M, Bai L, Zhuang W. A unique case of ectopic pancreas presenting as jejunal malignance. J Surg Case Rep. 2019;2019(7). doi:10.1093/jscr/rjz217\u003c/li\u003e\n\u003cli\u003eRezvani M, Menias C, Sandrasegaran K, Olpin JD, Elsayes KM, Shaaban AM. Heterotopic pancreas: Histopathologic features, imaging findings, and complications. Radiographics. 2017;37(2). doi:10.1148/rg.2017160091\u003c/li\u003e\n\u003cli\u003eKung JW, Brown A, Kruskal JB, Goldsmith JD, Pedrosa I. Heterotopic pancreas: typical and atypical imaging findings. Clin Radiol. 2010;65(5). doi:10.1016/j.crad.2010.01.005\u003c/li\u003e\n\u003cli\u003eKim JY, Lee JM, Kim KW, et al. Ectopic pancreas: CT findings with emphasis on differentiation from small gastrointestinal stromal tumor and leiomyoma. Radiology. 2009;252(1).\u003c/li\u003e\n\u003cli\u003eDistler M, R\u0026uuml;ckert F, Aust D, Saeger HD, Gr\u0026uuml;tzmann R. Pancreatic Heterotopia of the Duodenum: Anatomic Anomaly or Clinical Challenge? Journal of Gastrointestinal Surgery. 2011;15(4). doi:10.1007/s11605-011-1420-2\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Ectopic pancreas, Heterotopic pancreas, Jejunal mass, Gastric outlet obstruction, Submucosal lesion, Small bowel obstruction, Abdominal pain, Intestinal perforation, Histopathology, Case report","lastPublishedDoi":"10.21203/rs.3.rs-7557191/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7557191/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eEctopic pancreas (EP) is a rare congenital anomaly where pancreatic tissue is found outside the pancreas without any ductal or vascular connection. It is commonly located in the stomach but can also occur in the jejunum, ileum, liver, spleen, and other sites. EP is usually asymptomatic but can cause complications like inflammation, obstruction, or malignant transformation.\u003c/p\u003e\n\u003cp\u003eThis case report presents a patient with Ectopic Pancreas in the proximal jejunum, leading to gastric outlet obstruction. The patient had chronic abdominal pain and weight loss. Initial investigations, including endoscopic biopsies, were inconclusive, but contrast-enhanced CT suggested EP. Surgical intervention was performed due to persistent symptoms, revealing a contained jejunal perforation. Histopathology confirmed the Ectopic Pancreas and the patient recovered well postoperatively.\u003c/p\u003e\n\u003cp\u003eThis case highlights the diagnostic challenges of the Ectopic Pancreas. While imaging aids in diagnosis, histopathology remains the gold standard. Awareness of the ectopic Pancreas as a rare cause of gastric outlet obstruction is crucial for timely management.\u003c/p\u003e","manuscriptTitle":"Jejunal Ectopic Pancreas Causing Gastric Outlet Obstruction","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-11 11:16:32","doi":"10.21203/rs.3.rs-7557191/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"057a439c-0c7a-486c-8430-8d2d321283a9","owner":[],"postedDate":"September 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":54502694,"name":"Gastroenterology \u0026 Hepatology"},{"id":54502695,"name":"Internal Medicine"},{"id":54502696,"name":"Gastrointestinal Surgery"}],"tags":[],"updatedAt":"2025-09-11T11:16:32+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-11 11:16:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7557191","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7557191","identity":"rs-7557191","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}