A 68-year-old woman was admitted to hospital with a six-week history of abdominal pain and 6-kg weight loss. Her medical history revealed arterial hypertension, diabetes mellitus type II, sigma diverticulosis, cholecystectomy and hysterectomy. Family history was uneventful for bowel diseases. Esophagogastroscopy and colonoscopy detected no pathologies. Abdominal computed tomography demonstrated a circular stenosis of the distal ileum (Fig. 1a). Tumourous obstructive ileus was suspected, and explorative laparotomy was performed. Subtotal stenosis of the distal ileum and numerous small polypous lesions were detected in the small bowel. Thirty nine centimetres of small bowel was resected and displayed a central 4-cm circular stenosing, ulcerated tumour exhibiting a cystic cut surface. Furthermore, numerous smaller flat polypous lesions up to 3 × 2 cm were detected throughout the specimen displaying a central folded surface and cystic cross-section (Fig. 1b–d). On microscopic examination, ileal mucosa was interrupted by patchy glandular structures of gastric corpus and antrum differentiation, located mostly in the mucosa (Fig. 2a). Intraepithelial neoplasia was present in mucosa overlying heterotopic corpus glands (Fig. 2b). Cystic dilation of submucosal glands was observed corresponding to gastritis cystica profunda. In addition, an adenocarcinoma was originated in the heterotopia with submucosal infiltration (Fig. 2c). Immunohistochemical staining with cytokeratin (CK) 7 was positive in heterotopic glands, and CK20 stained positive in ileal mucosa. The adenocarcinoma displayed only CK7. Proliferative activity assessed by Ki67 was estimated at 60% in the adenocarcinoma. Finally, the diagnosis of multifocal heterotopic gastric mucosa in the distal ileum with gastritis cystica profunda and development of a 4-cm invasive adenocarcinoma was established and staged at pT3, pN0 (0/12), pMx, G2, R0 according to UICC 2010. Postoperative capsule endoscopy did not detect any more pathologies.

Heterotopic gastric mucosa is fairly infrequent but may be encountered throughout the gastrointestinal tract, usually as “inlet patch” in proximal oesophagus, duodenum or Meckel’s diverticulum [4]. The peculiar observation in our case was not only the multifocal gastric heterotopia but the combination with gastritis cystica profunda. The latter is characterized by hyperplastic and cystic dilation of pseudopyloric glands with extension into the submucosa or even muscular wall of the stomach. Its aetiology is still unclear. Ischaemia, chronic inflammation, mucosal injury, the effects of surgery and suture material are suggested to play a role in pathogenesis [5]. Gastritis cystica profunda is a benign lesion, although a possible precancerous nature has been hypothesized [5].