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Heterotopic pancreatic tissue is defined as pancreatic tissue outside the boundaries of the pancreas that has neither anatomic nor vascular continuity with the pancreas. Heterotopic pancreatic tissue in the gallbladder is uncommon and has rarely been reported to cause symptoms. We report a case of heterotopic pancreatic tissue obstructing the gallbladder neck resulting in cholecystitis.A 26-year-old female presented with right upper quadrant abdominal pain and fever. On physical examination the right upper quadrant was tender to palpation with a positive Murphy's sign. Laboratory tests were significant for elevated aspartate aminotransferase and alanine aminotransferase. Transabdominal sonography showed gallbladder wall thickening, a positive sonographic Murphy's sign, and an apparent large non-mobile stone at the gallbladder neck. Pathologic examination revealed cholecystitis but instead of a large stone there was a tan-yellow necrotic mass at the gallbladder neck. Microscopically, the mass consisted of heterotopic pancreatic tissue containing exocrine pancreatic acini, ducts, and islets of Langerhans. The final diagnosis was acute cholecystitis secondary to obstruction by heterotopic pancreatic tissue.Although heterotopic pancreatic tissue is usually an incidental finding on pathologic exam, one should not exclude it in the differential diagnosis of symptomatic gallbladder disease of indefinite etiology.

Aims To audit compliance with Scottish Intercollegiate Guidelines Network (SIGN) guideline 107: diagnosis and management of headache in adults for assessment and investigation of possible subarachnoid haemorrhage (SAH) in a 30 bedded medical assessment unit (MAU). Methods All cases presenting to the MAU in which SAH was a differential diagnosis were identified prospectively over a 4 week period. Medical notes, PACS and the computer lab results system were assessed for the following audit parameters: documentation of relevant symptoms and examination, performance of and timing of brain imaging, appropriately timed, documented and analysed lumbar puncture (LP). The results of the audit were relayed and discussed at the departmental teaching meeting and re–audit performed following this. Results 17 patients in 1st cycle and 24 in 2nd cycle identified during audit period. Time to peak headache intensity documented in 10/17 (58%) 1st cycle and 3/25 (12.5%) 2nd cycle. Full cranial nerve and peripheral nerve examination documented in 15/17 (88%) 1st cycle and 23/24 (96%) 2nd cycle. 16/17 (94%) 1st Cycle and 24/24 (100%) 2nd cycle patients received a CT Head with an average door–to–CT time of 8.2 hours 1st cycle and 6.5 hours 2nd cycle. 12/17 (70%) 1st cycle and 19/24 (79%) 2nd cycle received a LP. LP was performed>12 hours post headache in 11/12 (91%) 1st cycle and 19/19 (100%) 2nd cycle. LP opening pressures documented in 6/12 (50%) 1st cycle and 11/19 (58%) 2nd cycle. CSF spectrometry performed in 100% 1st and 2nd cycle (12/12 and 19/19 respectively). Conclusions Many aspects of assessment and investigation of SAH in the MAU were done very well such as a large proportion of patients getting timely brain imaging and performance of CSF spectrometry on all LP samples. Some aspects were suboptimal such as documentation of important red flag headache symptoms, LP not performed in a large portion of cases and LP opening pressures often not documented. There was an almost universal improvement on all parameters in the 2nd cycle after audit meeting and educational intervention. Further educational and organisational intervention is planned with a 3rd audit cycle following this.