• 70 year old female
  • Significant weight loss within last 6 months
  • Painless jaundice since 10 days, Associated with on and off Low grade fever
  • CT Abdomen and pelvis – 8 x 2.2 cm sized enhancing mass lesion in peri Ampullary region
    • Involvement of second part of duodenum with peri lesional fat stranding,
    • Abrupt cut off of CBD, Central and peripheral IHBRD, Dilated PD
  • EUS – A4 cm X 1.3 cm sized Ampullary mass with extension into the bile duct
    • Dilated Common Bile Duct and Main Pancreatic Duct
    • Echogenic bile was seen in the bile duct suggestive of purulent Cholangitis
    • A large hypoechoic node was seen in the pericholedochal region
    • IHBR appeared dilated in left lobe of liver.
    • No evidence of any hypoechoic lesions were seen in the left lobe of liver
  • ERC – Duodenoscopy revealed Ampullary growth
    • Selective cannulation of bile duct was achieved
    • Biliary Sphincterotomy was performed and multiple biopsies were taken
    • a 6 cm uncovered self expandable metallic stent was placed in the CBD
    • Free flow of purulent bile was seen from the placed stent
  • Diagnosis – Adenocarcinoma

Expert comments:-

  • Biliary SEMS (short intra pancreatic or covered) do not impede pancreatic resection and may be used for preoperative biliary drainage in patients with malignant CBD obstruction when surgical status is unknown.
  • Endoscopic treatment of adenomas of the major duodenal papilla is a safe, well tolerated alternative to surgical therapy1.
  • In expert hands, complications are rare and surgery is generally not required1.

Take home message:-

  • Acute ascending Cholangitis may be an initial presentation of Ampullary tumor and requires urgent biliary decompression with endoscopic biliary drainage2.
  • In purulent Cholangitis, plastic stent tends to block. In such cases Self Expandable Biliary Metal stents provide effective ductal decompression.
  • In resectable cases, the short biliary self expandable metal stent can be removed at the time of definite surgical intervention.
A 1.4cm X 1.3cm Ampullary mass

A 1.4cm X 1.3cm Ampullary mass

Echogenic bile was seen in the bile duct

Echogenic bile was seen in the bile duct

 

 

 

 

 

 

 

 

 

Ampullary tumor

Ampullary tumor

Biliary Sphincterotomy

Biliary Sphincterotomy

 

 

 

 

 

 

 

 

 

Free flow of purulent bile from SEMS

Free flow of purulent bile from SEMS

Multiple biopsies from the Ampullary growth

Multiple biopsies from the Ampullary growth

 

 

 

 

 

 

 

 

 

Cholangiogram showing dilated CBD with abrupt cutoff

Cholangiogram showing dilated CBD with abrupt cutoff

A 6 cm uncovered self expandable metallic stent

A 6 cm uncovered self expandable metallic stent

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