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Special Feature
May 01, 2008

Image of the Month—Diagnosis

Arch Surg. 2008;143(5):514. doi:10.1001/archsurg.143.5.514
Heterotopic Gastric Mucosa

A histologic examination of the excised specimen revealed heterotopic gastric mucosa (Figure 2). Although heterotopic gastric mucosa has been described to arise throughout the length of the alimentary tract, in the rectum it is a rare occurrence.1Most patients—about two-thirds—present with some degree of bleeding per rectum and about 10% complain of perianal pain.2Rarely, a patient will present with a complication of the heterotopic mucosa, such as rectovesicle or perianal fistula.2The lesion has a slight male predominance and symptoms tend to arise at a variety of ages, from the young to the middle aged.1,2

Figure 2.
The tissue biopsy specimen reveals glandular structures, pits, and focal foveolar-type tissue reminiscent of gastric mucosa (original magnification × 20).

The tissue biopsy specimen reveals glandular structures, pits, and focal foveolar-type tissue reminiscent of gastric mucosa (original magnification × 20).

Morphologically, these lesions most commonly present as either polyps or diverticula and the diagnosis is confirmed by an endoscopic biopsy that reveals gastric mucosa.2Fundic mucosa is the most common type isolated.2

The exact origin of the misplaced epithelium is unknown. A prominent theory suggests that this entity is the result of an error in the differentiation of pluripotent endodermal stem cells during development.2Occasionally, a patient has an associated congenital abnormality, such as a rectal duplication.3

Definitive therapy is by surgical excision, although H2blockers have been used to successfully alleviate symptoms, such as bleeding and pain, and this sometimes results in complete healing of the lesion without recurrence.2

The lesion we describe is not consistent with transsphincteric fistula-in-ano because no external opening was found. A fissure-in-ano would be expected to be located in the posterior midline and possibly be associated with a sentinel pile. The lesion's appearance is not typical of a rectal neoplasm, which would be expected to appear as either a sessile plaque or an exophytic polyp.

In conclusion, heterotopic gastric mucosa in the rectum is a rare occurrence. Despite its rarity, it is useful for general practitioners to be aware of this entity because the symptoms can often be relieved by H2blockers, just like the “stomachache” associated with gastritis.

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Submissions

Due to the overwhelmingly positive response to the Image of the Month, the Archives of Surgeryhas temporarily discontinued accepting submissions for this feature. It is anticipated that requests for submissions will resume in mid-2008. Thank you.

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Article Information

Correspondence:Joseph Mareno Jr, MD, Department of Surgery, University of California, San Diego, Medical Center, Mail Code 8402, 200 W Arbor Dr, San Diego, CA 92103 (jmareno@ucsd.edu).

Accepted for Publication:December 6, 2006.

Author Contributions:Study concept and design: Mareno, Takabe, and Bakhtar. Acquisition of data: Mareno, Takabe, and Ramamoorthy. Drafting of the manuscript: Mareno and Bakhtar. Critical revision of the manuscript for important intellectual content: Mareno, Takabe, and Ramamoorthy. Administrative, technical, and material support: Takabe and Bakhtar. Study supervision: Ramamoorthy.

Financial Disclosure:None reported.

Additional Contributions:Dr Bakhtar, Department of Pathology, University of California, San Diego, Medical Center reviewed the pathology slides.

References
1.
Carlei  FPietroletti  RLomanto  D  et al.  Heterotopic gastric mucosa of the rectum: characterization of endocrine and mucin-producing cells by immunocytochemistry and lectin histochemistry: report of a case. Dis Colon Rectum 1989;32 (2) 159- 164
PubMedArticle
2.
Steele  SRMullenix  PSMartin  MJ  et al.  Heterotopic gastric mucosa of the anus: a case report and review of the literature. Am Surg 2004;70 (8) 715- 719
PubMed
3.
Jordan  FTMazzeo  RJSoiderer  MH Heterotopic gastric mucosa of the rectum: a rare cause of rectal bleeding. Arch Surg 1983;118 (7) 878- 880
PubMedArticle
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