AJR 2003; 181:599-600
© American Roentgen Ray Society
Prolapse of the Common Bile Duct with Small Ampullary Villous Adenocarcinoma into Third Part of the Duodenum
Theodore R. Smith,
Daniel Berkowitz and
Andrei Frost
J. D. Weiler Hospital of the Albert Einstein College of Medicine and
Montefiore Medical Center Bronx, NY 10461
Prolapse of the common bile duct into the duodenum is extremely rare. A
review of the literature reveals only one previously reported case in which
prolapse of the common bile duct was associated with a 3-cm malignant
ampullary villous adenoma on a stalk
[1]. In the patient we present,
the leading point of the prolapse was a 2.5-cm malignant ampullary sessile
villous adenoma associated with marked dilatation of the common bile duct
(which was engorged by sludge and hemorrhagic material) and proximal biliary
obstruction.
Our patient was an 84-year-old man with a 2-month history of jaundice,
pruritus, and weight loss of 10 lb (4.5 kg). Abdominal CT (performed without
IV contrast material) showed biliary intra- and extrahepatic dilatation
(Fig. 3A). The pancreatic duct
was also slightly dilated. The common bile duct could be identified as a
dilated tubular structure with low attenuation (17 H) that projected into the
third portion of the duodenum (Fig.
3B). At the distal end of the duct was a small irregular
nipplelike protrusion with soft-tissue attenuation (67 H), a finding
consistent with a soft-tissue mass presenting as the leading point of the
prolapse, such as a neoplasm of the ampulla of Vater or of the common bile
duct itself or a choledochocele (the possibility of choledocholithiasis was
not excluded).
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Fig. 3B. —Images of 84-year-old man with jaundice. CT scan obtained 30 mm
inferior to A reveals villous adenocarcinoma with nipplelike protrusion
(arrowhead) at distal end of prolapsed common bile duct
(arrow) in third part of opacified duodenum.
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Endoscopic retrograde cholangiopancreatography (ERCP) revealed a smooth,
markedly elongated common bile duct that bulged into the proximal portion of
the third part of the duodenum. At the distal end of the duct, the ampullary
orifice was involved with a 2.5-cm nodular friable flat mass
(Fig. 3C), which correlated
with the CT findings. A fistulotomy proximal to the tumor resulted in rapid
extrusion of a clotted-bile cast of the common bile duct, a copious quantity
of bile, and no calculi. The patient's jaundice rapidly resolved, and ERCP
performed 10 days later showed the prolapsed common bile duct to have
retracted considerably. An attempted endoscopic resection was unsuccessful. A
subsequent Whipple procedure revealed a 2.5-cm villous adenocarcinoma that was
limited to the ampulla of Vater; no lymph nodes were positive for
carcinoma.
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Fig. 3C. —Images of 84-year-old man with jaundice. ERCP reveals prolapsed
common bile duct in third portion of duodenum. Note 2.5-cm villous
adenocarcinoma (arrow) in ampulla of Vater adjacent to cannula
(corresponds to finding in B).
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Because of their strategic location, ampullary adenomatous neoplasms are
usually symptomatic (e.g., jaundice, pruritis, acholic stools, or
cholangitis), often even if the tumor is relatively small. Prognosis for
patients with these tumors typically is better than the prognosis for patients
with pancreatic carcinoma or cholangiocarcinoma. Ampullary adenomatous
neoplasms are more common in men than in women, and patients who have other
gastrointestinal lesions (particularly colonic lesions) are at increased risk
for developing ampullary lesions. The risk is especially high in patients with
familial adenomatous polyposis syndrome. Treatment, when feasible, usually
consists of a Whipple en bloc resection.
On gastrointestinal imaging series (including hypotonic duodenography) of
these patients, one looks for an increased prominence (> 1.5 cm) of the
papilla of Vater, although the papilla is frequently seen as a
normal-appearing smooth indentation of the lumen that in rare cases can be as
large as 3 cm. MR imaging, ERCP, and CT may show the tumor and other findings
such as a "double duct" dilatation of the common bile duct and
pancreatic duct; however, small primary lesions are difficult to detect unless
projecting into the lumen or invading the duodenal wall
[2,
3].
The common bile duct and the papilla of Vater are substantially fixed, not
given to adjacent laxity. Prolapse of these structures is virtually unknown,
although a rare case of retrograde ampullary prolapse that produced
pseudocholedocholithiasis has been described
[4]. However, in the case of
our patient, the combination of the leading ampullary occlusive tumor and the
markedly increased intrabiliary pressure was presumed to have been sufficient
to produce an antegrade prolapse of the common bile duct.
References
- Chalmers N, DeBeaux AC, Garden OJ. Case report: prolapse of an
ampullary tumor beyond the duodenal–jejunal flexure. Clin
Radiol 1993;47:141
–142[Medline]
- Buck JL, Elsayed AM. Ampullary tumors: radiologic–pathologic
correlation. RadioGraphics1993; 13:193
–212[Abstract]
- Darweesh RM, Thorsen MK, Dodds WJ, Kishk SM, Lawson TL, Stewart ET.
Computed tomography examination of periampullary neoplasms. J
Comput Tomogr 1988;12:36
–41[Medline]
- Alberti-Fior JJ, Hernandez ME, Del Valle F. Endoscopic diagnosis of
the invaginating ampulla of Vater mimicking choledocholithiasis. Am
J Gastroenterol 1994;89:126
–127[Medline]
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