Ileoileocolic Intussusception Secondary to Isolated Ectopic Pancreatic Tissue: An Uncommon Case.

Sir,

A 10-year-old boy was admitted with chief complaints of abdominal pain, nausea, and vomiting for 3 days. He had not passed stool for 2 days. He had no significant past and personal history. Physical examination showed minimal abdominal distension with a palpable lump in the right lower quadrant. Ultrasonography of the abdomen revealed “bowel within bowel” appearance extending from the umbilical region and the right iliac fossa to the right upper abdomen; the length of the involved segment was 12 cm suggestive of ileocolic intussusception with an echogenic nodule as the lead point [Figure 1]. Laboratory investigations showed a low hemoglobin 9.0 g/dL, increased total leukocyte count (18,000/mm3), and high C-reactive protein level. Other blood investigations were within the standard limit. The patient was sent to the operating room after obtaining written informed consent. At exploration of the abdomen, an ileoileocolic intussusception extending up to the hepatic flexure was found and reduced manually. A small well-circumscribed nodule was observed as a lead point at 50 cm from the ileocecal valve [Figure 2]. We performed wedge resection and single layer closure with polyglactin 910, 3–0 suture. The resected specimen was sent for histopathological examination, which showed submucosal ectopic pancreatic tissue with Heinrich type 1 elements [Figure 3]. The postoperative course was unremarkable.

Figure 1

Bowel within bowel appearance with focal echogenic lead point within suggestive of intussusception secondary to the pathological lead point

Figure 2

A well-circumscribed nodule in the ileum

Figure 3

Ileal mucosa with submucosal ectopic pancreatic tissue composed of duct, acini, and islet cells (left, H and E stain, ×4; and right, H and E stain, ×40)

Ectopic pancreatic tissue or heterotopic pancreatic tissue is defined as pancreatic tissue lacking anatomical and vascular continuity with the pancreas and found anywhere within the abdomen.[1] Postmortem studies have demonstrated ectopic pancreatic tissue in approximately 0.55%–13.7% of autopsies.[2] Jean Schultz presented the first reported case of ectopic pancreatic tissue within a diverticulum in 1727.[2] It is most commonly found in the stomach, duodenum, and jejunum. The symptoms are related to size and mucosal relation.[2] Classic dictum teaches that the frequency of pathological lead point (PLP) in pediatric intussusception increases with age. However, Lin et al. found that those >2 years old, especially between 2 and 5 years of age (47.7%), were more likely to have PLPs than those >5 years old (30.8%).[3] Although the PLP is conventionally believed to be more common in older children as compared to younger, 97.4% of ileocolic intussusception cases were idiopathic regardless of the age.[4] On extensive literature search, we found 21 cases reported so far.[5] In a review of 21 cases with intussusception due to ectopic pancreatic tissue, 15 patients were <2 years of age. Only three cases over 4 years of age have been reported in the pediatric age group.[6] Ileoileocolic intussusception in pediatric patients over 4 years of age has not been reported to date. It is essential to look for the PLP, and palpation is required mainly for a submucosal location that may not be obvious on inspection. Resection is considered the treatment of choice to prevent recurrence. Von Heinrich has classified ectopic pancreas into three types. Type 1 ectopic pancreatic tissue is structured with ducts, acini, and islets. Type II ectopic pancreas shows ducts and acini while Type III consists of ducts only.

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Conflicts of interest

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