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Occult Heterotopic Gastric Mucosa as a Lead Point for Ileocolic Intussusception in an Adolescent: A Rare Finding with Inherent Diagnostic Challenges

Gastric heterotopia (aka heterotopic gastric mucosa, ectopic gastric mucosa) is a finding of gastric mucosa outside of the stomach. It can occur at any point along the gastrointestinal tract,1, 2 but is most often associated with Meckel’s diverticulum and intestinal duplication.13 Alternative, but more uncommon, presentations include segmental dilatation, gastrointestinal bleeding, bowel obstruction, and intussusception.2, 4–9 Intussusception, in particular, is one of the more unusual presentations, reported in only a handful of cases in the literature.1, 2, 4, 7–9 Diagnosis of gastric heterotopia typically occurs postoperatively during pathologic examination of a surgical specimen. This is in large part because of the difficulty in preoperative diagnosis and the limitations of current imaging modalities to identify the causal lesion. The only modality able to potentially offer presurgical diagnosis is technetium-99m pertechnetate scintigraphy that will highlight the ectopic tissue but is rarely a consideration if the child has a presentation that does not include a gastrointestinal bleed.3 In this report, we present the case of a 16-year-old male who was found to have intussusception caused by aberrant gastric mucosa within the ileum. This case highlights not only the diagnostic dilemma posed by gastric heterotopia but also one of the scarce findings in the current literature in which gastric heterotopia causes intussusception within the ileum.8 A 16-year-old white boy presented in transfer from an outside hospital with a 2-week history of worsening, paroxysmal abdominal pain. A CT scan performed by the referring facility demonstrated ileocolic intussusception. The patient reported no nausea, vomiting, changes in bowel habits, and sick contacts. His medical history was significant only for reports of “recurrent ileus” at the age of two with symptoms that ultimately abated after a negative workup, including upper and lower gastrointestinal endoscopy. On physical examination, the abdomen was soft with diffuse tenderness to palpation including rebound tenderness and signs of peritonitis. The patient was taken directly to the operating room for diagnostic laparoscopy. The ileocolic intussusception was reduced laparoscopically without event. A thorough examination of the bowel was performed; however, a pathologic lead point was not identified. The patient had an uneventful postoperative course, and was discharged the day after his operation. One week after surgery, the patient experienced abdominal pain that progressively became more severe. Furthermore, he described the pain as intermittent and aggravated by eating. He was seen initially at an outside hospital where a CT scan revealed small bowel wall thickening concerning for an intraluminal mass (Fig. 1). The patient was readmitted to our hospital, made nil per os, and nasogastric tube decompression was initiated. The subsequent workup included abdominal MRI that revealed focal wall thickening in the distal jejunum. In addition, a small focus of intussusception, without identifiable lead point, was visualized in the small intestine. A colonoscopy was performed to assist in localizing a pathologic lead point; however, the procedure was terminated after encountering an irreducible intussusception at the hepatic flexure. This mandated operative intervention and the patient was taken for exploration. The previous laparoscopic umbilical incision was reopened and widened caudally. The small bowel was eviscerated thereby delivering the intussuscepted ileocolic segment. The intussuscipiens was gently manipulated to expose the intussuscepted small intestine. Presented at 2016 Southeastern Surgical Congress Annual Scientific Meeting, Atlanta, Georgia, February 21, 2016. Address correspondence and reprint requests to Heather R. Nolan, M.D., Mercer University School of Medicine, The Medical Center Navicent Health, 777 Hemlock St, MSC #140, Macon, GA 31201. E-mail: heathernolan@ymail.com.