A rare case of periampullary carcinoma with ectopic ending of Vater's ampulla

A 71-year-old woman was referred to our department complaining of painless progressive jaundice for the last 3 mo. Magnetic resonance imaging and magnetic resonance cholangiopancreatography (MRCP) showed the ectopic hepatopancreatic ampulla draining into the fourth part of the duodenum adjacent to the duodenojejunal flexure; the irregular morphology of the duodenojejunal flexure likely due to a soft tissue mass. Laparotomy confirmed the presence of the abnormal ampulla of Vater located at the fourth part of the duodenum and a soft tissue tumor about 6 cm × 5 cm × 5 cm with a peduncle adjoining the ampulla. Resection of the tumor, including some peripheral tissue, and a Roux-Y loop anastomosis choledochojejunostomy were performed. Pathological examination indicated an intestinal villous adenoma accompanied by severe dysplasia and focal canceration. Periampullary carcinoma with ectopic ending of the Vater's ampulla into the fourth part of the duodenum is rather rare. The embryonic genetic background of this anomaly has not yet been fully explained. It is worth mentioning that MRCP is useful for demonstrating anomalies and anatomic variants of the biliary tract system and pancreatic duct.

Survival benefit of concurrent chemoradiotherapy for advanced ampulla of Vater cancer

BACKGROUND Currently,there is no standard adjuvant therapy for patients with resected ampulla of Vater(AoV)cancer.AIM To evaluate the effectiveness of adjuvant concurrent chemoradiotherapy(CCRT)in patients with advanced AoV cancer who underwent curative resection.METHODS This single-centered,retrospective study included 29 patients with advanced AoV cancer who underwent pancreaticoduodenectomy between 2006 and 2018.The impact of CCRT on advanced AoV cancer was analyzed.RESULTS The 1-,3-,and 5-yr recurrence-free survival(RFS)rates for patients with advanced AoV cancer were 82.8%,48.3%,and 40.8%,respectively,and the overall survival(OS)rates were 89.7%,62.1%,and 51.7%,respectively.Lymphovas-cular invasion was found to be a significant risk factor for RFS and OS in patients with advanced AoV cancer in the univariate analysis,whereas T stage and lymph node metastasis were significantly associated with OS in the multivariate analysis.Compared to the patients who did not receive adjuvant CCRT,those who received adjuvant CCRT did not show statistically significant improvements in the RFS and OS,although they had a significantly lower average age and significantly higher platelet-to-lymphocyte ratio.CONCLUSION Adjuvant CCRT did not improve survival outcomes in patients with advanced AoV cancer.These findings contribute to existing knowledge on the effectiveness of CCRT in this patient population and provide important insights for clinical decision-making.

Comparison of mismatch repair and immune checkpoint protein profile with histopathological parameters in pancreatic,periampullary/ampullary,and choledochal adenocarcinomas

BACKGROUND Pancreatic,periampullary/ampullary,and choledochal adenocarcinomas are aggressive malignancies with a poor prognosis.Immune checkpoint blockade is a promising treatment option for several tumor types.H long terminal repeatassociating 2(HHLA2),which is analogous to programmed death-ligand 1(PDL1),is a recently discovered member of the B7/cluster of differentiation 28 family and is expressed in many malignancies.AIM To analyze the expression of HHLA2 and its association with the pathologic biomarkers that predict sensitivity to immunotherapy.METHODS Ninety-two adenocarcinoma cases located in the pancreas,ampulla,and distal common bile duct were identified.This study assessed 106 pancreaticoduodenectomy and distal/total pancreatectomy samples that were delivered to Ankara City Hospital between 2019 and 2021.Immunohistochemistry was conducted to examine the expression of DNA mismatch repair(MMR),PD-L1,and HHLA2 proteins.RESULTS Patients with high HHLA2 expression had a higher mean age than those with low expression.Low HHLA2 expression was associated with high perineural invasion.HHLA2 expression was low in pathological stage T3(pT)3 cases and high in pathological stage T1,T2,and T4 cases.There was no correlation between HHLA2 expression and the expression of MMR proteins and PD-L1.CONCLUSION Evaluation of HHLA2 expression in microsatellite stable and PD-L1-negative tumors may be useful for predicting the response of individuals to immunotherapy and may serve as a novel therapeutic target for immunotherapy in advanced-stage disease.

The sperm-interacting proteome in the bovine isthmus and ampulla during the periovulatory period

Background Spermatozoa interact with oviduct secretions before fertilization in vivo but the molecular players of this dialog and underlying dynamics remain largely unknown.Our objectives were to identify an exhaustive list of sperm-interacting proteins(SIPs)in the bovine oviduct fluid and to evaluate the impact of the oviduct anatomical region(isthmus vs.ampulla)and time relative to ovulation(pre-ovulatory vs.post-ovulatory)on SIPs number and abundance.Methods Pools of oviduct fluid(OF)from the pre-ovulatory ampulla,pre-ovulatory isthmus,post-ovulatory ampulla,and post-ovulatory isthmus in the side of ovulation were collected from the slaughterhouse.Frozen-thawed bull sperm were incubated with OF or phosphate-buffered saline(control)for 60 min at 38.5℃.After protein extraction and digestion,sperm and OF samples were analyzed by nanoLC-MS/MS and label-free protein quantification.Results A quantitative comparison between proteins identified in sperm and OF samples(2333 and 2471 proteins,respectively)allowed for the identification of 245 SIPs.The highest number(187)were found in the pre-ovulatory isthmus,i.e.,time and place of the sperm reservoir.In total,41 SIPs(17%)were differentially abundant between stages in a given region or between regions at a given stage and 76 SIPs(31%)were identified in only one region×stage condition.Functional analysis of SIPs predicted roles in cell response to stress,regulation of cell motility,fertilization,and early embryo development.Conclusion This study provides a comprehensive list of SIPs in the bovine oviduct and evidences dynamic spatiotemporal changes in sperm-oviduct interactions around ovulation time.Moreover,these data provide protein candidates to improve sperm conservation and in vitro fertilization media.

Role of adjuvant chemotherapy on recurrence and survival in patients with resected ampulla of Vater carcinoma

BACKGROUND Owing to rarity of disease and lack of prospective studies, data supporting the role of adjuvant chemotherapy in ampulla of Vater(AoV) carcinoma is limited.AIM To evaluate whether adjuvant chemotherapy cases for AoV carcinoma had better disease-free survival(DFS) rates than cases of observation following curative surgery.METHODS We retrospectively analyzed the association between adjuvant chemotherapy and DFS and overall survival(OS) in patients with stage IB-Ⅲ AoV carcinoma who underwent curative surgical resection. Fluorouracil-based adjuvant chemotherapy was administered after surgery at the discretion of the physician. Adjusted multivariate regression models were used to evaluate the association between adjuvant chemotherapy and survival outcomes.RESULTS Of the total 104 patients who underwent curative surgery, 52 received adjuvant chemotherapy. Multivariate analysis revealed that higher histologic grade [hazard ratio(HR) = 2.24, P = 0.046], advanced tumor stage(HR = 1.85, P = 0.030), and vascular invasion(HR = 2.14, P = 0.010) were associated with shorter DFS. Adjuvant chemotherapy improved DFS compared to the observation group(HR =0.50, P = 0.015) and tended to be associated with a longer OS, although the difference was not statistically significant(HR = 0.58, P = 0.098).CONCLUSION Among patients with resected AoV carcinoma, the adjuvant chemotherapy group was not associated with a significant survival benefit compared to the observation group. However, on multivariate analysis adjusting for prognostic factors, adjuvant chemotherapy following surgery was an independent prognostic factor for DFS in patients with resected AoV carcinoma. Further studies are needed to investigate the effectiveness of adjuvant chemotherapy according to histologic phenotype.

Acute pancreatitis following endoscopic ampullary biopsy:A case report

BACKGROUND Endoscopic biopsy is mandatory for the diagnosis of malignant and premalignant ampullary tumours.The commonly reported inadvertent complications following routine mucosal biopsy include perforation and haemorrhage.Acute pancreatitis is an extremely rare complication following this procedure.CASE SUMMARY This report details the case of a 59-year-old man who underwent biopsy of the ampulla for a suspected periampullary tumour.Following the procedure,the patient presented with symptoms of acute pancreatitis which was substantiated by laboratory and radiological investigations.He was conservatively managed and discharged following complete resolution of symptoms.CONCLUSION This case report serves to highlight the importance of this potential complication following routine endoscopic biopsy of the ampulla.

壶腹部神经内分泌肿瘤的研究进展

壶腹部神经内分泌肿瘤(ampullary neuroendocrine neoplasm,A-NEN)发病率低、分类复杂且临床病理特点多样。随着A-NEN报道数量的增加,研究者对本病的认识正在不断深化。然而,由于一些临床工作者对A-NEN的认识存在不足,使得部分患者未能获得最佳的诊治。A-NEN发病初期的临床表现不典型,许多患者发现时已处于进展期。提高A-NEN的早期诊断率、明确A-NET的内镜治疗指征,以及寻找更有效的抗肿瘤治疗靶点是目前研究的重点。本文以各种类型A-NEN的临床病理特征为出发点,对诊断及治疗的相关进展进行综述,为A-NEN患者的个体化治疗提供参考依据。

胆管癌(包括 Vater's 乳头癌)52例分析

胆管癌较少见，尸检发现率为0．01－0．85％（1），临床症状不典型，术前诊断靠影像学检查，主要靠逆行胰胆管造影（以下简称ERCP），径皮肝穿胆管造影（以下简称PTC）和CT检查（2），我院从1978年以来，在2000多例ERCP，PTC直接法胆道造影中，发现胆管癌包括乳头癌104例，其中44例经手术证实，8例经直接内窥镜下活检证实，现就这52例总结分析如下。

不同内镜逆行胰胆管造影术复杂度分级量表在内镜医师培训中的效用比较

目的探讨不同内镜逆行胰胆管造影术(ERCP)的复杂度分级,在内镜医师培训中的效用。方法收集2022年2月-2023年2月华东地区两家医院由进修培训医师完成ERCP治疗的237例患者的临床资料。所有ERCP病例均使用已提出的复杂度分级量表进行分类,包括:美国消化内镜学会(ASGE)分级量表、Morriston分级量表和HOUSE分级量表,并与肝胰壶腹解剖特征分类进行比较。记录患者插管成功率、手术治疗成功率和48 h内并发症发生率。结果在每一分级中,按严重程度分为亚组,3种不同分级中,亚组组间插管成功率比较,差异有统计学意义(P=0.000),亚组组间治疗成功率比较,差异有统计学意义(P=0.000);并发症发生率与ASGE分级(P=0.361)、Morriston分级(P=0.332)、HOUSE分级(P=0.586)之间没有相关性。当只考虑具有原始乳头的病例时,新加入肝胰壶腹解剖特征分类,插管成功率取决于复杂度分级。ASGE组中,亚组间插管成功率比较,差异有统计学意义(P=0.004);Morriston组中,亚组间插管成功率比较,差异有统计学意义(P=0.002);HOUSE组中,亚组间插管成功率比较,差异有统计学意义(P=0.000);肝胰壶腹特征组中,亚组间插管成功率比较,差异有统计学意义(P=0.000);治疗成功率与插管成功率亦有相似的发现(P=0.000);并发症发生率与ASGE分级(P=0.586)、Morriston分级(P=0.443)、HOUSE分级(P=0.306)和肝胰壶腹特征分类(P=0.350)之间没有相关性。结论使用肝胰壶腹解剖特征,作为胆管插管复杂度分类是可行的,其可以成为一种替代或附加手段,来预测胆管插管和手术治疗是否成功,未来也可用于评估内镜医师培训学习进度和技术水准。

胰头癌与壶腹癌的超声鉴别诊断

目的:总结胰头癌与壶腹癌的超声影像学特点,以更好地鉴别诊断胰头癌与壶腹癌。方法:回顾性分析2020年4月—2023年4月榆林市子洲县人民医院手术病理确诊的胰头癌、壶腹癌患者各40例的临床资料和超声检查结果。分析超声对不同病灶的检出率、病灶最大直径分布情况(>3 cm与≤3 cm)、主要超声影像学资料表现情况。结果:胰头癌组、壶腹癌组的超声检出率比较,差异无统计学意义(P>0.05)。胰头癌组病灶最大直径>3 cm占比高于壶腹癌组,差异有统计学意义(P<0.001)。两组淋巴结肿大、内部低信号比较,差异无统计学意义(P>0.05);胰头癌组癌组织形态规则、边界清晰、无血管侵犯占比低于壶腹癌组,胰头癌组有血流信号占比高于壶腹癌组,差异有统计学意义(P<0.05)。结论:超声对胰头癌、壶腹癌的检出率较高,超声影像学检查能够为鉴别诊断胰头癌、壶腹癌提供参考。

Trends in incidence and management of cancer of the ampulla of Vater

AIM:To provide trends in incidence,management and survival of cancer of the ampulla of Vater in a welldefined French population.METHODS:Data were obtained from the populationbased digestive cancer registry of Burgundy over a34-year period.Age-standardized incidence rates were computed using the world standard population.Average annual variations in incidence rates were estimated using a poisson regression.A univariate and multivariate relative survival analysis was performed.RESULTS:Age-standardized incidence rates were0.46 and 0.30 per 100000 inhabitants for men and women,respectively.Incidence rate increased from0.26(1976-1984)to 0.58(2003-2009)for men and remained stable for women.Resection for cure was performed in 48.3%of cases.This proportion was stable over the study period.Among cases with curative resection,pancreatico-duodenectomy was performed in94.0%of cases and ampullectomy in 6.0%of cases.A total of 50.8%of cancers of the ampulla of Vater were diagnosed at an advanced stage.Their proportion remained stable throughout the study period.The overall1-and 5-year relative survival rates were 60.2%and27.7%,respectively.Relative survival did not vary over time.Treatment and stage at diagnosis were the most important determinants of survival.The 5-year relative survival rate was 41.5%after resection for cure,9.5%after palliative surgery and 6.7%after symptomatic treatment.In multivariate analysis,only stage at diagnosis significantly influenced the risk of death.CONCLUSION:Cancer of the ampulla of Vater is still uncommon,but its incidence increased for men in Burgundy.Diagnosis is often made at an advanced stage,dramatically worsening the prognosis.

Ampullary neuroendocrine tumor diagnosed by endoscopic papillectomy in previously confirmed ampullary adenoma

Ampullary adenoma is a common indication for endoscopic papillectomy. Ampullary neuroendocrine tumor(NET) is a rare disease for which complete surgical resection is the treatment of choice. However, because of the morbidity and mortality associated with surgical resection, endoscopic papillectomy is increasingly used in selected cases of low grade, with no metastasis and no invasion of the pancreatic or bile duct. Also, confirmed and complete endoscopic resection of ampullary NET accompanied by adenoma has not been reported to date. We report herein a rare case of an ampullary NET accompanied with adenoma, which was successfully and completely resected via endoscopic papillectomy. Prior to papillectomy, this case was diagnosed as an ampullary adenoma.

Management of ampullary neoplasms: A tailored approach between endoscopy and surgery

Ampullary neoplasms,although rare,present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region.No specific guidelines about their management are available,and they are often assimilated either to biliary tract or to pancreatic carcinomas.Due to their location,they tend to become symptomatic at an earlier stage compared to pancreatic malignancies.This behaviour results in a higher resectability rate at diagnosis.From a pathological point of view they arise in a zone of transition between two different epithelia,and,according to their origin,may be divided into pancreatobiliary or intestinal type.This classification has a substantial impact on prognosis.In most cases,pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour.The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported.In selected situations less invasive approaches,such as ampullectomy,have been advocated,although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas.Importantly,these methods have the drawback of not including an appropriate lymphadenectomy,while nodal involvement has been shown to be frequently present also in apparently lowrisk carcinomas.Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound.In the present paper the evidence currently available is reviewed,with the aim of offering an updated framework for diagnosis and management of this specific type of disease.

Impact of periampullary diverticula on the outcome and fluoroscopy time in endoscopic retrograde cholangiopancreatography

BACKGROUND: It is unclear whether the presence of periampullary diverticula (PAD) affects technical success and complication rates during endoscopic retrograde cholangio- pancreatography (ERCP). Moreover, the impact of PAD on fluoroscopy duration is still unknown. The present study aimed to investigate the success rate and difficulty of common bile duct (CBD) cannulation, post-procedure complications and fluoroscopy duration in patients with and without PAD. METHODS: Patients from January 2008 to December 2010 with PAD (group A) and without PAD (group B) and similar indications for therapeutic ERCP were prospectively compared. The comparison included patient characteristics, findings of ERCP, and details of procedure and fluoroscopy time. The influence of papilla’s location with respect to the diverticulum on procedure was also investigated. RESULTS: A total of 428 consecutive patients who had undergone therapeutic ERCP for similar indications were divided in two groups according to the presence (group A, 107 patients) or absence (group B, 321 patients) of PAD. The mean age and ASA score of the patients with PAD were significantly higher than those patients without PAD. The main indication was choledocholithiasis. Successful final CBD cannulation was achieved in 97.20% of the patients in group A vs 99.69% in group B (P=0.05). CBD diameter, number of stones and the largest stone size were significantly higher in group A thangroup B (P【0.001). Complete clearance of the CBD after the first attempt was achieved in 85.86% and 94.75% of the patients in groups A and B, respectively (P=0.03). In both groups, the time needed to complete the procedure and fluoroscopy time was significantly longer in patients with PAD (22.87 vs 18.99 minutes, P【0.001; 76.51 vs 47.42 seconds, P【0.001). There was no significant difference between the two groups in the complication rate. The type of papilla’s location with respect to the diverticulum did not influence the total cannulation rate and post-procedure complications. CONCLUSION: The presence of a PAD does not affect the success rate and complications of therapeutic ERCP in expert hands; however, the fluoroscopy time is significantly longer in patients with PAD.

Neuroendocrine carcinoma of the ampulla of Vater:a clinicopathologic evaluation

BACKGROUND:Only 105 cases of neuroendocrine tumor(NET)of the ampulla of Vater have been described, mostly as single case reports.The incidence of NET is rising.The changes in incidence may result from changes in detection.This study was to determine the relative incidence and clinicopathological characteristics of high- grade neuroendocrine carcinoma(small cell carcinoma and large cell carcinoma)of the ampulla of Vater at a single institution. METHODS:Sections from paraffin blocks of tumors of the ampulla of Vater taken from 45 patients who underwent Whipple’s procedure and 6 patients who underwent palliative bypass between September 2003 and January 2007 were subjected to immunohistochemical analysis.The clinical and pathological data from 5 patients diagnosed with NET of the ampulla of Vater were analyzed. RESULTS:The patients were 3 men and 2 women,ranging in age from 39 to 47 years(mean 44 years).Operative procedures included Whipple’s procedure in 4 patients and palliative bypass in 1 patient.Histopathological examination revealed large-cell neuroendocrine carcinoma in 2 patients,small cell carcinoma in 2,and carcinoid in 1.Three patients with high-grade neuroendocrine carcinoma who had undergone Whipple’s procedure died at postoperatively 7,11,and 13 months.The patient who had undergone palliative triple bypass died 3 months after surgery.CONCLUSIONS:The relative incidence of high-grade neuroendocrine carcinomas of the ampulla of Vater is higher than that generally expected.The tumors behave aggressively and have a dismal prognosis despite aggressive treatment.

Melanoma in the ampulla of Vater

BACKGROUND:The most common tumors in the ampulla of Vater are adenocarcinomas.Although malignant melanoma usually occurs on the skin,it can also arise in the gastrointestinal and biliary tract.METHOD:We present a case of a 52-year-old,previously healthy man who presented with painless jaundice.RESULTS:Clinical examination revealed dilated intrahepatic and extrahepatic bile ducts and pancreatic duct due to the obstructive mass in the ampulla of Vater.The patient underwent pancreaticoduodenectomy and histopathological diagnosis of the resected tumor mass was malignant melanoma.Thorough clinical examination was preformed,but no other primary or metastatic site of melanoma could be found.In the next few months,the patient developed multiple liver metastases and died.CONCLUSION:An isolated amelanotic lesion in the ampulla of Vater can be a potential diagnostic pitfall,especially in patients who have had melanoma.

Gastrointestinal stromal tumor of the ampulla of Vater:A case report

Gastrointestinal stromal tumors(GISTs)usually develop in the stomach and small intestine and only rarely occur at the ampulla of Vater,with only 11 cases reported in the literature.We report a case of a GIST of the ampulla of Vater.A 36-year-old,previously healthy man presented with a loss of consciousness lasting a few minutes.A gastroduodenal endoscopy revealed a submucosal tumor with central ulceration at the ampulla of Vater.The enhanced computed tomography scan revealed a smooth-outlined hypervascular solid mass(24 mm×30 mm)in the second part of the duodenum.Neither lymphadenopathy nor metastasis was observed.Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography showed normal bile and pancreatic ducts.Biopsies were collected from the ulcerative lesion,and the tumor was diagnosed as a GIST.A submucosal tumor with central ulceration may be a characteristic form of GISTs of the ampulla of Vater,and biopsy studies are useful for the diagnosing such tumors.The patient underwent pancreatoduodenectomy,and the operative specimen revealed a 2.2-cm GIST with 1 mitosis per 50 highpower fields.The gold standard for treatment of GISTs is surgical resection without rupture of a capsule.If technically possible,local resection may be considered.However,when the location of the lesion presents challenges,a pancreatoduodenectomy should be performed for GIST of the ampulla of Vater.

Prognostic relevance of number and ratio of metastatic lymph nodes in resected carcinoma of the ampulla of Vater

Objectives： To explore the prognostic relevance of the number and ratio of metastatic lymph nodes in resected Carcinoma of the ampulla of Vater （CAV）. Methods： The clinical data of 155 patients who underwent pancreaticoduodenectomy （PD） for cancer of the ampulla of Vater between January 1990 and December 2010 were retrospectively analyzed. Kaplan- Meier method was used in survival analysis and Log rank method in comparison. Multivariate analysis was performed using Cox proportional hazards model. Results： Among these 155 patients, the in-hospital mortality rate was 4.5%, lymph node positive disease was 21.3%, and the 5-year survival rate was 51.6%. Patients with a lymph node ratio （LNR） 〉20% were more likely to have tumor differentiation, depth of duodenal involvement, depth of pancreatic invasion, T-stage and TNM-Stage. The number of the metastatic lymph nodes is important prognostic factors of the CAV. Univariate analysis showed that the factors associated with the prognosis included tumor size （P=0.036）, tumor differentiation （P=0.019）, LNR （P=0.032）, mtmber of metastatic lymph nodes （P=0.024）, lymph node metastasis （P=0.03）, depth of pancreatic invasion （P=0.001）, T-stage （P=0.002）, TNM stage （P=0.001）, elevated CA 19-9 （P=0.000）, and jaundice （P=0.021）. Multivariate analysis showed that the factors associated with the prognosis were the number of metastatic lymph nodes （P=0.032; RR： 1.283; 95% CI： 1.022-1.611）, tumor size （P=0.043; RR： 1.736; 95% CI： 1.017-2.963）, and elevated CA 19-9 （P=0.003; RR： 3.247; 95% CI： 1.504-7.010）. Conclusions： LNR is a useful factor for predicting the prognosis of the radical treatment for CAV,, whereas the number of metastatic lymph nodes is the most important factor. Further research on the locations, number, and LNR will be clinically meaningful to improve survival in patients with CAV.

Endoscopic ultrasound in the papilla and the periampullary region

Endoscopic ultrasound (EUS) provides relevant information when an ampullary or periampullary tumor is suspected.Early detection, T and N staging and Fine Needle Aspiration plus cithologic confirmation, are some of the expected benefits. Exclusion of benign findings like choledocholithiasis or chronic pancreatitis is also important. A correct understanding of the complex ampullary and periampullary anatomy is needed. Knowledge of the individual clinical history and other previous diagnostic images all contribute to a successful EUS examination. Radial and lineal EUS images are uniquely detailed and, at the moment, it seems to be the best way to exclude or confirm malignant or benign findings. We propose a procedural algorithm, including EUS,for suspected ampullary or periampullary tumors. This review summarizes the vast amount of information to be found spread in the literature, and recognizes this small anatomic area as the origin for a clinical entity with proper clinical presentation, proper imaging and proper therapeutic resolutions. The benefits of performing EUS for its study are highlighted.

Amiodarone hepatotoxicity complicating obstructive jaundice due to ampullary cancer

BACKGROUND:The presence of dual pathology can cause diagnostic dilemmas. We present a case of adenocarcinoma of the ampulla of Vater with concurrent amiodarone hepatotoxicity. METHODS:Painless jaundice associated with a palpable gallbladder was investigated clinically,radiologically endoscopically and via liver biopsy. RESULTS:Liver biopsy showed amiodarone hepatotoxicity Endoscopic biopsy identified an ampullary adenoma However,the endoscopic ultrasound and intra-operative findings suggested a malignancy,which was confirmed postoperatively. CONCLUSIONS:While the classic findings of Courvoisier’s Law are borne out in this case,the etiology of jaundice is twofold. Although dual pathology is uncommon it should always be considered.