Acquired Heterotopic Gastric Mucosa after Gastrojejunostomy Tube Placement Causing Intermittent Obstruction

Sameer Lapsia, M.D., Clinical Fellow in Pediatric Gastroenterology. Anupama Chawla, M.D., Chief, Division of Pediatric Gastroenterology. Juan Carlos Bucobo, M.D., Assistant Professor of Medicine/ Gastroenterology. Rupinder Gill, M.D., Assistant Professor of Pediatric Gastroenterology. SUNY at Stony Brook, Health Science Center, Stony Brook, NY predominantly antral type gastric mucosa and occasional oxyntic cells (Figure 2). A distinct zone of demarcation was present between the heterotopic gastric mucosa and normal intestinal mucosa. There was no evidence of metaplasia, dysplasia or malignancy. Due to the patient’s recurrent episodes of emesis, a repeat esophagogastroduodenoscopy was performed and the polyp was removed using snare cauterization. CASE PRESENTATION An otherwise healthy 14 year-old obese male presented after suffering secondand thirddegree burns to over 40% of his body surface area including his face, arms and chest while attempting to light a tiki torch. His hospital course was complicated by acute respiratory distress syndrome, acute kidney injury and sepsis. Due to an anoxic brain injury resulting in disturbed oral-motor function, the patient had a percutaneous gastrostomy tube (G-tube) placed to provide enteral feeding. Despite radiographic studies showing patency of the G-tube he began to have episodes of non-bilious vomiting after feeds. An upper gastrointestinal (UGI) series as well as a computed tomography (CT) scan of his abdomen showed no signs of obstruction or dilated loops of bowel. After a successful trial with nasojejunostomy (NJ) tube feeds, a gastrojejunostomy (GJ) tube was placed endoscopically to provide postpyloric feeds. At that time, no mucosal abnormalities of the duodenum or proximal jejunum were appreciated. Approximately 6 weeks later, he again presented with intermittent emesis, now occasionally bilious. An UGI series showed the tip of the jejunostomy tube had migrated back into the stomach. No obstructive bowel gas pattern was noted. Repeat endoscopy to reposition the jejunal portion of the GJ tube was performed. A 2.5 cm semi-pedunculated salmon-red colored polyp was noted in the distal duodenum/proximal jejunum (Figure 1) causing partial obstruction of the lumen. Biopsies revealed heterotopic gastric tissue with