Introduction

Ampullary adenoma develops from the ampulla in the second part of the duodenum, typically affecting elderly individuals, more commonly men than women. It can cause biliary obstruction (jaundice) and intermittent gastrointestinal bleeding when it enlarges and ulcerates. Mild anemia and abnormal liver function tests (LFTs) are common initially, with clinical jaundice occurring in the later stages. These lesions carry a high risk of malignancy.

Case Presentation

A 75 year old female presented with itching for the last four months and deranged LFTs with an obstructive pattern. She had a previous history of pancreatitis and non-Hodgkin lymphoma (NHL) but no relevant hepato-biliary problems.

Diagnostic Assessment

The patient’s routine blood tests revealed mild anemia and an obstructive pattern in liver function tests. An ultrasound of the abdomen showed a normal gallbladder, mild intrahepatic biliary radicle dilatation (IHBRD), and a dilated proximal common bile duct (CBD). Magnetic Resonance Cholangiopancreatography (MRCP) confirmed the presence of IHBRD and a dilated CBD, but no mass lesion was detected, and the pancreas appeared normal. 

Further diagnostic procedures, including Endoscopic Ultrasound (EUS) and Oesophago-gastro duodenoscopy (OGD), identified an ampullary adenoma with a peri-ampullary carpet adenoma. Biopsies taken from both sites confirmed the presence of adenoma without any malignancy.

Treatment Approach

The treatment options for the patient included endoscopic resection, clinical monitoring (for asymptomatic elderly patients), and surgical intervention (Whipple’s procedure) in cases of confirmed malignancy. 

In this case, the patient underwent a successful therapeutic endoscopy and complete resection of the lesion through ampullectomy, along with the removal of surrounding abnormal tissue by EMR technique. This was followed by an ERCP to ensure complete removal.

Outcome

The patient recovered well and was discharged the next day, with histology confirming the complete excision and ruling out malignancy.

Discussion

Ampullary adenomas are successfully treated by minimally invasive resection in over 95% of cases. The risk of pancreatitis can be mitigated by placing pancreatic stents, and minor bleeding can be managed with current instruments. This procedure, while technically challenging, is performed under light sedation by skilled endoscopists.

Conclusion

Endoscopic resection of ampullary adenomas can be performed successfully with minimal invasiveness, requiring the expertise of experienced endoscopists. Regular follow-up ensures patients remain free of malignancy. Our patient made an uneventful recovery and remains healthy post-procedure.

References

• Trung KV, Abou-Ali E, Caillol F, et al. Endoscopic papillectomy for ampullary lesions in patients with familial adenomatous polyposis compared with sporadic lesions: a propensity score-matched cohort. Endoscopy. 2023;55(08):709-718. doi:10.1055/a-2029-2935
• Fritzsche, J.A., Klein, A., Beekman, M.J. et al. Endoscopic papillectomy; a retrospective international multicenter cohort study with long-term follow-up. Surg Endosc 35, 6259–6267 (2021). https://doi.org/10.1007/s00464-020-08126-x
• Gupta S, Craciun A, Wang H, et al. Hybrid resection versus conventional resection for laterally spreading lesions of the papilla. Gastrointestinal Endoscopy. 2024;99(3):428-436. doi:10.1016/j.gie.2023.10.034
• Spadaccini M, Fugazza A, Frazzoni L, et al. Endoscopic papillectomy for neoplastic ampullary lesions: A systematic review with pooled analysis. United European Gastroenterology Journal. 2020;8(1):44-51. doi:10.1177/2050640619868367

About Author –

Dr. Santosh Enaganti, Senior Consultant Gastroenterologist & Hepatologist, Advanced Interventional Endoscopist , Yashoda Hospitals - Hyderabad
MD, MRCP, CCT (Gastro) (UK), FRCP (London)

Dr. Santosh Enaganti

MD,MRCP CCT(Gastro) (UK), FRCP

Senior Consultant
Gastroenterologist & Hepatologist,
Advanced Interventional Endoscopist

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