A 59-year male presented with worsening nausea/emesis, diarrhea and weight loss for 1 month. His medical history was notable for nonischemic cardiomyopathy requiring pacemaker and other co-morbidities. Physical exam elicited epigastric and right upper quadrant tenderness. Labs were notable for elevated lipase and liver function tests (LFTs). Abdominal ultrasound (US) showed distended gallbladder with intraluminal sludge, intrahepatic and common bile duct (CBD) dilation. Magnetic resonance cholangiopancreatography could not be performed given his cardiac pacemaker. Treatment for acute biliary pancreatitis was promptly started. Esophagogastroduodenoscopy (EGD) with endoscopic ultrasound (EUS) revealed a filling defect without clear post acoustic shadowing in distal CBD (Figure 1A). During the ERCP, balloon sweep made after sphincterotomy exposed polypoid tissue at the ampulla (Figure 1B and C) and a CBD stent was placed. His symptoms and LFTs continued to improve. Biopsy of ampullary tissue revealed tubulovillous adenoma (Figure 1D). After 2 months, he underwent repeat ERCP at which a 2.5 cm ampullary mass was resected after mucosal lifting, CBD and pancreatic duct stent were placed. Biopsy of the ampullary mass confirmed tubulovillous adenoma without any dysplasia. Surveillance ERCP showed unremarkable cholangiogram and pancreatogram without any residual adenoma.
Figure 1.
(A) EGD with EUS revealed a filling defect without clear post acoustic shadowing in distal CBD. (B and C) During the ERCP, balloon sweep made after sphincterotomy exposed polypoid tissue at the ampulla. (D) Biopsy of ampullary tissue revealed tubulovillous adenoma.
On EUS evaluation, lack of postacoustic shadowing should raise suspicion for potential obstructive etiologies other than stones (1). Though infrequent, large intraductal ampullary adenomas can obstruct the pancreatic duct causing acute pancreatitis that warrants prompt evaluation and management (2). Endoscopic management is a safe and effective treatment for such lesions (3).
Conflict of Interest
The authors disclose no conflicts.
References
- 1. Castillo C. “Endoscopic ultrasound in the papilla and the periampullary region.” World J Gastrointest Endosc 2010;2(8):278. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Chini P, Draganov PV. Diagnosis and management of ampullary adenoma: The expanding role of endoscopy. World J Gastrointest Endosc 2011;3(12):241–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Patel R, Davitte J, Varadarajulu S and Wilcox C. “Endoscopic resection of ampullary adenomas: Complications and outcomes.” Dig Dis Sci 2011;56(11):3235. [DOI] [PubMed] [Google Scholar]