Journal of Regional Section of Serbian Medical Association in Zajecar

Year 2010     Vol 35     No 1-2
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      UDK 616.33-002:616.342

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

Case review

Gastric ulcer in duodenum - or duodenal ulcer on polypoid changed heterotopic gastric mucosa - A case review
(Ulkus želuca u duodenumu ili ulkus duodenuma
na polipoidno izmenjenoj heterotopičnoj sluznici želuca - Prikaz slučaja

Zoran Joksimović (1), Hakija Bašić (2), Dušan Bastać (3)



This work presents a rare case of gastric mucosa heterotopia in duodenal bulb with ulceration. During the upper digestive endoscopy of a sixtyseven-year old female patient, we found a polypoid mass with craterous recesses and necrosis. Histopathological review showed that it was heterotopic gastric mucosa of fundus type with signs of chronic gastritis. The urease test for helicobacter pylori was positive. Control endoscopy after therapy showed a regression of inflammatory and necrotic changes. Repeated histopahological review confirms the microscopic picture of fundus gastric mucosa, but without the elements of inflammation. What is discussed is a need for distinguishing heterotopia from metaplasia and neoplasm, whereby histopathological diagnosis plays the main role.
Key words: mucosa heterotopia, ulcer, stomach, duodenum

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



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].


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


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

Figure 1 Endoscopic finding

Figure 2 Histopathological finding
      The ureasa test for H pylori from fundous and anthral mucosa was positive. Ultrasound examination of upper abdomen showed no changes. Total colonoscopy – diverticulosis of Sigmoid colon was without noticeable changes at the level of mucosa. The laboratory findings of red and white blood count and basic biochemical parameters were within reference values.
The female patient received the eradication therapy (Omeprazol, Amoxicilin, Metronidazol for a week) and very soon all subjective symptoms disappeared. We continued the therapy with Bismuth and Ranitidine for a month. At the control endoscopy after six weeks (14/1/2010), the ulcerations was repaired “ad integrum” as well as the signs of peptic bulbitis. Polypoid change was unchanged in size and form. The biopsy was repeated and histopathological examination showed the glands of stomach fundous type. Phoveolar regions were with hyperplastic mucin secreting epithelium. The other parts of glands were parietal and general cells.


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.


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.





  1. Nawaz H, Graham GY, Fechner RE, Eiband JM. Gastric heterotopia in the ileum with ulceration and chronic bleeding. Gastroenterology 1974;66:113-7
  2. Taylor AL. The epithelial heterotopia of the alimentary tract. J Pathol 1927:30:415-449
  3. Mann N. S. ; Mann S. K. ; Rachut E. ; Heterotopic gastric tissue in the duodenal bulb Journal of clinical gastroenterology 2000, vol. 30, no3, pp. 303-306 .
  4. Cecilia M. Fenoglio-preiser, Amy E. Noffsinger, Grant N. Stemmermann Gastrointestinal Pathology: An Atlas and Text Third Edition Lippincott Williams & Wilkins 2008, 312-313
  5. Agha F,Gary G., Ghahremani G,Tsang Tat-Kin , Heterotopic Gastric Mucosa in the Duodenum: Radiographic Findings Victors AJR:150, February 1988 , 291-4
  6. Picard EJ, Picard JJ, Jorissen J, Jardon M. Heterotoic gastric mucosa in the epiglottis and rectum. Digestive diseases and sciences 1978;23:217-20.
  7. Cappell M S. ; Lapin S ; Rose M Large Right Atrial Myxoma Containing Gastric Heterotopia Presenting with Dyspnea and Bilateral Leg Edema due to Pulmonary Emboli and Cardiovascular Obstruction : The First Known Report of Gastric Heterotopia in the Cardiovascular System; Digestive diseases and sciences 2008, vol. 53, no2, pp. 405-409
  8. Bender E, Schmidt S P Extraintestinal heterotopic gastric tissue simulating acute appendicitis World J Gastroenterol. 2008 April 14; 14(14): 2268–2269. Published online 2008 April 14. doi: 10.3748/wjg.14.2268.
  9. Wolff M. Heterotopic gastric epithelium in the rectum: A report of three new cases with a review of 87 cases of gastric heterotopia in the alimentary canal. Am J Clin Pathol 1971;55:604-16.
  10. Hoedemaeker Ph.J. Heterotopic Gastric Mucosa in the Duodenum Digestion 1970;3:165-173
  11. Smithuis R H , Vos C G Heterotopic gastric mucosa in the duodenal bulb: relationship to peptic ulcer American journal of roentgenology. 01/02/1989; 152
  12. X.B. Li, Z.Z. Ge, X.Y. Chen, and W.Z. Liu Duodenal gastric metaplasia and Helicobacter pylori infection in patients with diffuse nodular duodenitis Braz J Med Biol Res. 2007 Jul;40(7):897-902.
  13. A M Lessells and D F Martin Heterotopic gastric mucosa in the duodenum J Clin Pathol. 1982 June; 35(6): 591–595.
  14. Fujisawa et all Duodenal adenoma of gastric foveolar fenotype in the second portion of the duodenum Digestive Endoscopy, Volume 18, Number 1, January 2006 , pp. 62-66(5)
  15. J. M. Jepsen et all Prospective Study of Prevalence and Endoscopic and Histopathologic Characteristics of Duodenal Polyps in Patients Submitted to Upper Endoscopy Scandinavian Journal of Gastroenterology, Volume 29, Issue 6 June 1994 , pages 483 - 487
  16. Kibria R et all Heterotropic Gastric Tissue in Duodenal Bulb Mimicking Duodenal Cancer: An Unusual Duodenal Lesion J Gastrointest Canc 2009 november 6
  17. Kohan E et all Duodenal Bulb Mucosa with Hypertrophic Gastric Oxyntic Heterotopia in Patients with Zollinger Ellison Syndrome Diagnostic and Therapeutic Endoscopy Volume 2009
      Corresponding Address:
Zoran Joksimović
Cara Lazara 12, 19210 Bor
Article submitted: 28.01.2010.
Article accepted: 11.03.2010.
Article Internet issued: 11.11.2010.
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Timočki medicinski glasnik, Zdravstveni centar Zaječar
Journal of Regional section of Serbian medical association in Zajecar
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