CASE OF THE WEEK – “Duodenal bulb ectopic pancreas diagnosed by Endoscopic Ultrasound (EUS) guided Biopsy” by Dr. Piyush Somani, HOD & Specialist, Gastroenterology, NMC Royal Hospital Sharjah

CASE OF THE WEEK – “Duodenal bulb ectopic pancreas diagnosed by Endoscopic Ultrasound (EUS) guided Biopsy” by Dr. Piyush Somani, HOD & Specialist, Gastroenterology, NMC Royal Hospital Sharjah

Duodenal bulb ectopic pancreas diagnosed by Endoscopic Ultrasound (EUS) guided Biopsy

36 years male was referred for endoscopic ultrasound for large subepithelial lesion detected in the duodenal bulb on routine upper gastrointestinal endoscopy.

Upper gastrointestinal endoscopy revealed 1.5 cm polypoidal subepithelial (submucosal) lesion in the duodenal bulb.

The endoscopic ultrasound (EUS) revealed 15.76 mm X 10.31 mm heterogeneous predominantly hypo-echoic polypoidal, regular, oval shaped lesion probably arising from the submucosa (3rd layer)/muscularis propria (4th layer). Mucosa/ Muscularis mucosae/serosa appears to be normal and not involved by the hypo-echoic lesion.

Biopsy/FNAC was reviewed by Dr. Ehsan Ahmed (Histopathologist) which was suggestive of features of ectopic pancreas. Patient was reassured about the benign nature of the lesion.a The differential diagnosis of duodenal bulb subepithelilal lesions include Gastrointestinal stromal tumour, neuroendocrine tumour, leiomyoma, brunner gland hyperplasia, duplication cyst and ectopic pancreas.

EUS is the investigation of choice for subepithelial (submucosal) lesions in the entire gastrointestinal tract as CT/MRI will not reveal the origin of the wall layer. The wall layers origin defines the nature of lesion. Ther are five layers of the wall in the gastrointestinal tract 1) mucosa 2) muscularis mucosae 3) submucosa 4) muscularis propria and 5) serosa.

Each layer gives origin to different lesions. Leiomyoma arises from 2nd and 4th layer. Neuroendocrine tumour, brunner gland hyperplasia, duplication cyst and ectopic pancreas arises from the 3rd layer. Gastrointestinal stromal tumour arises from the 4th layer.

EUS guided biopsy/FNAC is a minimally invasive day-care procedure to make diagnosis in subepithelial (submucosal) lesions. This facility is available only in few hospitals in UAE.

Duodenal bulb ectopic pancreas diagnosed by Endoscopic Ultrasound (EUS) guided Biopsy 02 Duodenal bulb ectopic pancreas diagnosed by Endoscopic Ultrasound (EUS) guided Biopsy 03 Duodenal bulb ectopic pancreas diagnosed by Endoscopic Ultrasound (EUS) guided Biopsy 04