Year : 2009 | Volume
: 52 | Issue : 3 | Page : 397--399
Long segment ileal duplication with extensive gastric heterotopia
Sunitha Jacob1, Anand Mani1, VP Singh2, William Bhatti2,
1 Department of Pathology, Christian Medical College & Hospital, Ludhiana, India
2 Department of Plastic Surgery, Christian Medical College & Hospital, Ludhiana, India
Department of Pathology, Christian Medical College and Hospital, Ludhiana - 141 008, Punjab
Duplications of the alimentary tract are rare congenital anomalies which can be found at all levels of the alimentary tract. Majority of the duplications present as spherical cysts and usually range from a few millimeters to less than ten centimeters in size. Duplications produce complications such as intestinal obstruction or hemorrhage. A two-month-old infant presented with recurrent episodes of bleeding per rectum. Laparotomy revealed a giant ileal duplicated bowel segment which exhibited extensive gastric heterotopia with focal ulceration.
|How to cite this article:|
Jacob S, Mani A, Singh V P, Bhatti W. Long segment ileal duplication with extensive gastric heterotopia.Indian J Pathol Microbiol 2009;52:397-399
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Jacob S, Mani A, Singh V P, Bhatti W. Long segment ileal duplication with extensive gastric heterotopia. Indian J Pathol Microbiol [serial online] 2009 [cited 2019 Dec 13 ];52:397-399
Available from: http://www.ijpmonline.org/text.asp?2009/52/3/397/55006
Gastrointestinal tract duplications are uncommon congenital abnormalities with an incidence of one in 4500 births.  They are, by definition, located in or adjacent to the wall of the gastrointestinal tract, have smooth muscle in their walls and are lined by alimentary tract mucosa.  Majority of the duplications are diagnosed by two years of age.  Duplications may initially present with symptoms of bleeding or obstruction or they may be asymptomatic and discovered incidentally.  The risk of peptic ulceration due to presence of ectopic gastric mucosa and the rare occurrence of malignant transformation within the duplication remain secondary therapeutic concerns. ,
A two-month-old male baby was brought to the casualty with bleeding per rectum of one day duration. Clinical examination revealed no abnormality. X-ray abdomen was normal. Meckel's scan showed large irregular tracer uptake in the right lower abdomen. The baby was suspected to have Meckel's diverticulum or intussusception and was operated upon. Intraoperatively a 38 cm long para-mesenteric, tubular communicating duplication segment was seen 20 cm proximal to the ileo-cecal junction. The segment was resected and an end to end anastomosis was done.
The duplicated portion of the small intestine measured 38 cm in length [Figure 1]. The serosa was grossly unremarkable. On cutting open, the duplicated (mesenteric) segment was dilated, with thickened and granular mucosa and an ulcer measuring 1.2 0.2 cm. This segment was seen to be communicating at both its ends with the ileum. The normal segment (antimesenteric) showed normal intestinal folds.
Microscopic examination revealed a common muscular wall shared between the duplicated segment and the definitive ileum. The muscle layer was extremely attenuated and lost at places. The antimesenteric segment was lined by small intestinal mucosa which was unremarkable. Almost the entire duplicated (mesenteric) loop showed lining by gastric type of mucosa which in many areas showed specialized body type glands as well. The surface epithelium of the gastric mucosa was predominantly villiform [Figure 2]. The ulcer showed unhealthy granulation tissue layered over with necrotic debris. No H. pylori could be identified in the areas with gastric type of mucosa. No focus of intestinal metaplasia was detected in the ectopic gastric mucosa with Alcian blue-periodic acid Schiff staining. A final diagnosis of ileal duplication with gastric heterotopia and peptic ulceration in the duplicated segment was made.
Alimentary tract duplications are rare congenital anomalies that can occur in any portion of the gastrointestinal tract from the mouth to the anus. William Ladd was the first to coin the phrase 'duplication of the alimentary tract' in 1937 for anomalies which had a well-developed coat of smooth muscle, an epithelial lining from the alimentary tract and an attachment to some part of the alimentary tract. 
The etiology of alimentary tract duplications has not been well-characterized. Hypotheses have included intrauterine vascular accidents, abortive attempts at twinning, persistence of embryonic diverticulum or from incomplete recanalization, and the split notocord theory. ,,,
Although they can be encountered in patients of any age, majority of the duplications are found in infants or children, with a slight predominance in males. ,,, A few patients with alimentary tract duplications have associated congenital malformations of the skeletal or the genitourinary system. ,
Small-bowel duplications frequently present with vomiting, abdominal distension/pain or the presence of an abdominal mass, which may be due to intestinal obstruction secondary to volvulus or intussusception. , Duplications with gastric heterotopia are liable to present with recurrent abdominal pain or rectal bleeding as a result of peptic ulceration or viscus perforation. , The present case also presented with bleeding per rectum secondary to peptic ulceration in the duplicated segment.
Most studies report the ileum to be the favored location for duplications of the alimentary tract accounting for 30 - 60% of the lesions. ,, However, according to some other studies, the cecum is a more common site of duplication.  Duplications can be cystic or tubular. Spherical cysts constitute 82% of gastrointestinal tract duplications and are prevalent at all levels of the gastrointestinal tract. This type usually does not communicate with the lumen. Tubular variants constitute 18% of the cases and are most often encountered in small and large bowel. They frequently communicate with the lumen of the adjacent gut or outside the genitourinary system.  The length of the duplicated segment is less than 10 cm in 90% of the cases; rarely it can go up to 70 cm.  The duplicated intestinal segment is located on the mesenteric border of the intestine in contrast to Meckel's diverticulum which is seen on the antimesenteric side of the bowel. ,
Ectopic tissue is present in 30% of all the duplications, and can be comprised of gastric, squamous, transitional or ciliated mucosa or pancreatic tissue. ,,
A small proportion of alimentary tract duplications which persist into adult life can undergo malignant transformation. These cases show predominance in females, mostly occur between 35 to 65 years of age and arise more commonly in large-bowel duplications. The resultant tumors are usually adenocarcinoma of colonic or gastric type and rarely squamous carcinoma. ,
This case of intestinal duplication is unusual because it involved a long segment and exhibited extensive gastric heterotopia with focal peptic ulceration accounting for the main symptomatology.
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