ISSN 0350-2899, 35(2010) br.1-2 p 32-36

Napomena: kompletan tekst rada na srpskom jeziku
Note: full text in Serbian

INTRODUCTION

Heterotopia in terms of histology means the appearance of normal tissue on abnormal location. Pathogenesis of heterotypic gastric mucosa is unknown until the end, and by the origin it can be congenital and acquired [1]. Heterotopia of gastric mucosa in duodenum was first described in 1927 [2]. The most common endoscopic form of heterotypic gastric mucosa in duodenum is in a form of spotty changes with superficial erosion and/or ulcerations, or in a form of polypoid formation. Polypoid changes of duodenum on a phon of heterotypic gastric mucosa are rare with prevalence of 0.5-2% [3]. Usually, they do not do not exceed 1.5 cm in diameter. They are revealed accidentally or incidentally, because they are often asymptomatic. Symptoms may be initiated when the obstruction or intussusception appears on them or the peptic ulceration is developed on them [4]. Often heterotypic mucosa is a little different from duodenal mucosa and it is recognized only at histopathological examination [5].

THE AIM OF WORK

Presentation of duodenum ulcer on a phon of polypoidic heterotypic gastric mucosa as a rare entity.

REVIEW OF THE CASE

A 67-years old female patient came to an examination on 1/12/2009 due to pains in epigastrium, heartburn, nausea, emesis and constipation. Discomforts had lasted for a few months and partially discount on the H2-receptor blockers. By physical findings, we concluded a painful sensitivity in epigastrium. Upper digestive endoscopy showed, in duodenal bulb, directly behind pylorus on the posterior wall, an irregular polypoide mass, diameter about 12 mm, which in general was 2-3 mm above the level of mucosa bulbous, light lobic surface and, in the middle, it had a craterous recess and field of elliptical necrosis of the largest diameter from 3 to 4 mm. Mucosa of the rest of duodenum to the Vateri papilla was hyperemic. Diagnosis: Sessil duodenal polyp with ulcer.
Figure 1 Histopathological finding of biopsy of the described change showed a heterotypic fundus gastric mucosa that was present as differentiated gastric glandular epithelium with general parietal cells. The signs of chronic atrophic gastritis with infiltration of mucosa of polymorphonuclear leucocytes and lymphocytes were registered. Figure 2

DISCUSSION

Heterotypic gastric mucosa in other parts of the GIT is macroscopically visible or microscopic re-cognized mainly as accidental or incidental findings during endoscopy, surgical intervention or autopsy. The exception is the Mecken's diverticulum that, in the case of setting up the clinical suspicion, is proved by radioisotope. Heterotypic gastric mucosa can be found in all parts of the GIT and outside the digestive tract: mouth, tongue, oesophagus, larynx, lungs, heart, gall bladder, hepatic ducts, pancreas, bladder, small intestine, mesentery, colon, rectum, anus [6, 7, 8].
Congenital heterotopia of gastric mucosa is usually localized on oesophagus, duodenum and Mecken's diverticulum and less frequently on ileum and jejunum. Heterotypic tissue in these cases is mainly composed of general and parietal cells [2]. Congenital type of gastric heterotopias is often manifested as bleeding ulcus lesion. Ulcers appear due to the heterotypic tissue ability to produce gastric acid and pepsin [3]. The acquired variants of heterotopias are common in ileum and jejunum due to the regenerative changes of mucosa within the regional enteritis [3]. In the acquired heterotopias, the abnormal (gastric) mucosa contains more secreting mucous cells, while the parietal and general cells are mostly absent [9]. Heterotypic gastric mucosa is often significantly present in duodenum during resection of duodenal ulcer. Some authors believe that this was caused by a combination of high gastric acidity and duodenal ulcer [10].
Heterotopias should be distinguished from metaplasia. Metaplasia is a change of one kind of totally differentiated tissue in a completely differentiated tissue in the chronic inflammation process. The bottom of oesophagus and duodenal bulb are often the hosting of gastric metaplasia. Metaplasia of these parties seems that it has a protective role in relation to gastric acid [11]. Gastric metaplasia surrounds the parts of mucosa where the fields of thicken mucosa are mixed with native tissue. It is important to make a distinction of metaplasia from heterotopias because metaplasia is associated with duodenitis and often with helicobacter pylori infection, which must be adequately treated [12]. Heterotopias of gastric mucosa in duodenum does not generally present a serious clinical problem [13, 14, 15], but the endoscopic findings can be impressive with ulceration and necrosis and mimic a malignoma image [16, 17]. Therefore, the biopsy of detected changes and histopathological review of bioptate are of great importance.

CONCLUSION

We presented a rare histopathological phenomenon of polypoid heterotopia of gastric mucosa in duodenum with ulcer. Regarding the endoscopic findings, clinical features, histopathological features of biopted mucosa and the absence of signs of regional enteritis, we concluded that the female patient had a congental gastric heterotopia. Since heterotopia of gastric mucosa had no higher malignant potential as compared to the native mucosa, and the therapy led to the sanation of ulceration and bulbitis, we thought that the patient should not be operated, but only have a regular endoscopic follow. In such cases, histopathological findings are decisive in differential diagnosis of neoplasia.

LITERATURE

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