Heterotopic gastric mucosa in the anus and rectum: first case report of endoscopic submucosal dissection and systematic review

Abstract

Background: Heterotopic gastric mucosa (HGM) is the most reported epithelial heterotopia, but it is very rare in the rectum and anus.

Methods: The first case of an asymptomatic adult male with a large nonpolypoid HGM in the low rectum underwent complete resection by endoscopic submucosal dissection (ESD) is reported. The systematic review was based on a comprehensive search of MEDLINE, EMBASE and Google Scholar. Studies on humans were identified with the term 'heterotopic gastric mucosa in the rectum and /or anus.'

Results: The search identified 79 citations, and 72 cases were evaluated comprising the present report. Congenital malformations were observed in 17 (24%) patients; rectal duplication accounted for most of the cases. The HGM was located in the anus and perineal rectum in 25 cases (41%) and low, middle and proximal pelvic rectum in 20 (33%), five (8%) and 11 cases (18%), respectively. Morphology was nonpolypoid in 37 cases (51%), polypoid in 26 cases (36%) and ulcerated in nine cases (13%). Specific anorectal symptoms were reported by 50 (69%) patients of the whole study population, and by 33 (97%) of 34 patients ≤ 18 years. Complications were observed in 23 cases (32%). The HGM was excised in 50 cases (83%). Endoscopic resection was performed in 17 cases (34%); resection was piecemeal in five of 12 lesions ≥15 mm, required argon plasma coagulation in two cases and was associated with residual tissue in two (17%). Intestinal metaplasia and an adenoma with low-grade dysplasia were described in three adults (4%).

Discussion: This systematic review shows that the HGM in the rectum and anus may be associated with specific rectal symptoms and serious complications, mainly in the pediatric population, and a risk of malignancy in adults. Its complete excision should be recommended, and the ESD can overcome the technical limits of conventional endoscopic snare resection and avoid unnecessary surgery.

Keywords: endoscopic submucosal dissection; heterotopic gastric mucosa; rectum; review.

Figure 1.

Heterotopic gastric mucosa in the low perineal rectum. (A) slightly elevated non-granular superficial lesion at white-light; (B) chromoendoscopy with indigo carmine in the retroflexed view.

Figure 2.

Endoscopic submucosal dissection: (A) resection site; (B) resected specimen 30 x 30 mm pin-oriented on foam.

Figure 3.

Histology (hematoxylin & eosin staining) showing heterotopic gastric mucosa of pyloric type in the rectum: (A) seriated section (magnification x5); (B) magnified view of border between gastric and rectal epithelium (boxed area in figure 3a) (magnification x10); C) predominant pyloric mucous glands with rare parietal (P) and endocrine (E) cells (magnification x20).