Gastric heterotopia with features of gastritis cystica ...

J Case Rep Images Pathol 2017;3:17¨C19.

case-reports/jcrp

CASE REPORT

CLINICAL

IMAGE

Thirumala et al.

17

ACCESS

PEER REVIEWEDOPEN

| OPEN

ACCESS

Gastric heterotopia with features of gastritis cystica

profunda involving rectum: A case report

Thirumala V., Pathapati S., Thirumala S.

CASE REPORT

A 51-year-old male underwent an elective outpatient

endoscopy for an average risk colon screening. An

erythematous flat lesion, measuring about 2.5 cm in its

greatest diameter was noted in the rectum (Figure 1)

and biopsies were obtained. Histological examination

revealed multiple fragments of gastric oxyntic mucosa

with mild chronic inflammation (Figure 2) and several

foci of prolapsed glands in the stroma consistent with

gastritis cystica profunda. Transitional gastric oxyntic

mucosa and colonic epithelium were also noted (Figure

3). Testing for Helicobacter pylori organisms was

negative.

DISCUSSION

Gastric heterotopia of rectum is a rare finding with

approximately 70 cases reported in English literature. In

1939, Ewell et al. reported first case of gastric heterotopia

in rectum. Subsequently, several other case reports

have been reported [1]. Foregut and midgut derived

organs including esophagus, duodenum and Meckel¡¯s

diverticulum are most commonly involved sites followed

by rectum. Other extremely unusual sites include

mediastinum, spinal cord and scrotum [2¨C4]. Painless

rectal bleeding was the most common presentation

followed by diarrhea, tenesmus and abdominal pain.

Other symptoms and clinical presentations though rare

Figure 1: Endoscopic image of rectum showing flat to slightly

raised lesion.

Thirumala V.1, Pathapati S.2, Thirumala S.3

Affiliations: 1BS Neurosciences (Pre Med Student), UT Austin, TX; 2MD Gastroenterology, Amarillo Endoscopy, Amarillo, TX; 3MD, Director of Surgical Pathology, Ameripath

Lubbock, TX.

Corresponding Author: Vani Thirumala, BS Neurosciences

(Pre Med student), UT Austin, TX; Email: sdthirumala@



Received: 19 September 2017

Accepted: 04 October 2017

Published: 17 October 2017

Figure 2: High power view of gastric oxyntic mucosa (H&E

stain, x40).

Journal of Case Reports and Images in Pathology, Vol. 3, 2017.

J Case Rep Images Pathol 2017;3:17¨C19.

case-reports/jcrp

Figure 3: High power view of transitional colonic and gastric

oxyntic mucosa (H&E stain, x40).

include bowel perforation, megacolon, intussusception,

perianal and recto-vesical fistulas. The patient did not

present with any clinical symptoms and a sessile polyp

was discovered on routine screening colonoscopy.

In a large meta-analytic study to date, Iacopini et

al. [5] analyzed 78 reported cases of gastric heterotopia

involving rectum. In their study, they observed a wide

range in the age from 0.5 year to 69 years with a median

age of 22 years and 66% of the patients in their study were

male. On endoscopic evaluation, 51% of these lesions

were non-polypoid in appearance followed by polypoid

and ulcerated morphology in 49% of the cases. On

histologic evaluation, gastric oxyntic mucosa was most

commonly observed (83%) followed by mixed oxyntic

and pyloric type mucosa (11%) and pyloric type mucosa

(3%). It is interesting to note that our case demonstrated

oxyntic mucosa with features of prolapse consistent with

gastritis cystica profunda. To the best of our knowledge,

this finding in rectum has not been reported in literature.

Schaffer et al. reported a case of adenocarcinoma of the

ileum arising from multifocal gastric heterotopia with

gastritis cystica profunda [6].

Though, the exact mechanism of gastric heterotopia

is not known, several theories have been postulated

including inflammatory ¨Cadaptive response of native

anatomic site with resultant metaplastic change [7],

abnormal differentiation of pluripotent endodermal stem

cells [8]. Beck et al. proposed possible role of homeobox

genes for promoting epithelial differentiation in the

presence of local inflammation [9].

Diagnosis of gastric heterotopia by histologic

examination is usually straightforward with almost no

differential diagnosis. However, major pitfall to be aware

of, is floaters and contaminants. We reported the initial

biopsy specimen results from our patient as possible

contaminant ¨Cfloaters and requested repeat biopsies

which once again showed gastric mucosa and a diagnosis

of gastric heterotopia was made. Though, histamine 2

receptor blockers are helpful in treating rectal bleeding,

removal by surgical-endoscopic method is treatment of

choice and curative. It is unknown if gastric heterotopia

Thirumala et al.

18

in rectum confers an increased risk for malignant

transformation. Ko et al. reported first case of an invasive

adenocarcinoma of the transverse colon arising from

gastric heterotopia [10]. Immunohistochemically, the

tumor exhibited gastric phenotype [CK7+, MUC5AC+,

CK20-, CDX2-, MUC2-]. It is difficult to accurately

estimate the true incidence of malignant transformation

in gastric heterotopia of rectum due to relatively small

number of cases reported in literature. Intriguingly,

possibility of under estimated risk could be secondary to

obliterated small focus of heterotopia or non-sampling

of small heterotopic gastric mucosa in adenocarcinomas

and hence complete removal and surveillance is

recommended in all cases.

CONCLUSION

Gastric heterotopia is a rare finding in rectum and

recognition of potential pitfalls including contaminants,

floaters and artifacts is important to render a definitive

diagnosis. Though, unknown about their potential risk

for malignant transformation complete excision of these

lesions is advised.

Keywords: Adenocarcinoma, Gastric heterotopia, Gastritis cystica profunda

How to cite this article

Thirumala V., Pathapati S., Thirumala S. Gastric

heterotopia with features of gastritis cystica

profunda involving rectum: A case report. J Case Rep

Images Pathol 2017;3:17¨C19.

Article ID: 100016Z11TV2017

*********

doi:10.5348/Z11-2017-16-CL-5

*********

Author Contributions

Vani Thirumala ¨C Substantial contribution concept and

design, Acquisition of data, Drafting the article, Revising

it critically for important intellectual content, Final

approval of the version to be published

Srinivas Pathapati ¨C Substantial contribution concept

and design, Acquisition of data, Drafting the article,

Revising it critically for important intellectual content,

Final approval of the version to be published

Seshadri Thirumala ¨C Substantial contribution concept

and design, Acquisition of data, Drafting the article,

Revising it critically for important intellectual content,

Final approval of the version to be published

Journal of Case Reports and Images in Pathology, Vol. 3, 2017.

J Case Rep Images Pathol 2017;3:17¨C19.

case-reports/jcrp

Guarantor

Thirumala et al.

4.

The corresponding author is the guarantor of submission.

5.

Conflict of Interest

Authors declare no conflict of interest.

Copyright

? 2017 Vani Thirumala et al. This article is distributed

under the terms of Creative Commons Attribution

License which permits unrestricted use, distribution

and reproduction in any medium provided the original

author(s) and original publisher are properly credited.

Please see the copyright policy on the journal website for

more information.

6.

7.

8.

REFERENCES

1.

2.

3.

Ewell GH, Jackson RH. Aberrant gastric mucosa in

the rectum with ulceration and hemorrhage. World J

Surg 1939;38:641¨C3.

Willis RA. Some unusual developmental heterotopias.

Br Med J 1968 Aug 3;3(5613):267¨C72.

Khan MA, Fitzgerald RJ. Heterotopic gastric tissue in

the scrotum. J Urol 1996 Jun;155(6):2061.

Access full text article on

other devices

9.

10.

19

Knight G, Griffiths T, Williams I. Gastrocystoma of

the spinal cord. Br J Surg 1955 May;42(176):635¨C8.

Iacopini F, Gotoda T, Elisei W, et al. Heterotopic

gastric mucosa in the anus and rectum: First case

report of endoscopic submucosal dissection and

systematic review. Gastroenterol Rep (Oxf) 2016

Aug;4(3):196¨C205.

Schaefer IM, Sch¨¹ler P, Enders C, et al. High

chromosomal instability in adenocarcinoma of the

ileum arising from multifocal gastric heterotopia

with gastritis cystica profunda. Med Oncol 2011

Dec;28(4):1023¨C6.

Srinivasan R, Loewenstine H, Mayle JE. Sessile

polypoid gastric heterotopia of rectum: A report of

2 cases and review of the literature. Arch Pathol Lab

Med 1999 Mar;123(3):222¨C4.

Wolff M. Heterotopic gastric epithelium in the rectum:

A report of three new cases with a review of 87 cases of

gastric heterotopia in the alimentary canal. Am J Clin

Pathol 1971 May;55(5):604¨C16.

Beck F, Chawengsaksophak K, Waring P, Playford

RJ, Furness JB. Reprogramming of intestinal

differentiation and intercalary regeneration in Cdx2

mutant mice. Proc Natl Acad Sci U S A 1999 Jun

22;96(13):7318¨C23.

Ko H, Park SY, Cha EJ, Sohn JS. Colonic

adenocarcinoma arising from gastric heterotopia: A

case study. Korean J Pathol 2013 Jun;47(3):289¨C92.

Access PDF of article on

other devices

Journal of Case Reports and Images in Pathology, Vol. 3, 2017.

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download