Ahmad, Saba, MD

Brodsky, Jeffrey, MD

Enriquez, Miriam L, MD

Hickey, Patrick, DO

Shah, Hiral, MD

Sullivan, Matthew, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineAdenomyomatous Hyperplasia of the Ampulla ofVater Masquerading as Malignancy: A Case SeriesPatrick Hickey DOLehigh Valley Health Network, Patrick.Hickey@lvhn.orgSaba Ahmad MDLehigh Valley Health Network, Saba.Ahmad@lvhn.orgMatthew Sullivan DOLehigh Valley Health Network, Matthew.Sullivan@lvhn.orgMiriam L. Enriquez MDLehigh Valley Health Network, Miriam_L.Enriquez@lvhn.orgJeffrey Brodsky MDLehigh Valley Health Network, Jeffrey_T.Brodsky@lvhn.orgSee next page for additional authorsFollow this and additional works at: http://scholarlyworks.lvhn.org/medicinePart of the Gastroenterology Commons, Medical Sciences Commons, Other Medical SpecialtiesCommons, and the Surgery CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtHickey, P., Ahmad, S., Sullivan, M., Enriquez, M., Brodsky, J. & Shah, H. (2014, October 17). Adenomyomatous Hyperplasia of theAmpulla of Vater Masquerading as Malignancy: A Case Series. Poster session presented at the American College of GastroenterologyAnnual Scientific Meeting, Philadelphia, PA.AuthorsPatrick Hickey DO, Saba Ahmad MD, Matthew Sullivan DO, Miriam L. Enriquez MD, Jeffrey Brodsky MD,and Hiral Shah MDThis poster is available at LVHN Scholarly Works: http://scholarlyworks.lvhn.org/medicine/488© 2014 Lehigh Valley Health NetworkReferences:1	 	Choi	Y,	Kim	M,	Park	S,	et	al.	Clinical,	pathological,	and	immunohistochemical	features	of	adenomyoma	in	the	ampulla	of	vater.	The Korean Journal Of Gastroenterology = Taehan Sohwagi Hakhoe Chi.	December	2013;62(6):352-358.	2	 	Handra-Luca	A,	Terris	B,	Couvelard	A,	Bonte	H,	Flejou	J.	Adenomyoma	and	adenomyomatous	hyperplasia	of	the	Vaterian	system:	clinical,	pathological,	and	new	immunohistochemical	features	of	13	cases.	Modern Pathology: An Official Journal Of The United States And Canadian Academy Of Pathology, Inc. June	2003;16(6):530-536.3	 	Kumari	N,	Vij	M.	Adenomyoma	of	ampulla:	a	rare	cause	of	obstructive	jaundice.	Journal Of Surgical Case Reports.	August	1,	2011;2011(8):6.Background•		Definition:	Adenomyomas	are	benign	lesions	likely	composed	of	heterotopic	pancreatic	tissue	rarely	seen	in	the	ampulla	of	Vater	•		Patient Presentation:		Biliary	obstruction,	abnormal	liver	tests,	imaging	abnormalities,	and/or	incidental	discovery•		Endoscopic	sampling	of	the	papilla	may	show	epithelial	cell	atypia	suggesting	dysplasia	•		Patients	often	undergo	invasive	surgical	resection	for	presumed	malignancy•		Case Series:	Two	patients	that	underwent	surgery	for	distal	common	bile	duct	(CBD)	brushings	with	malignant	cytology,	but	final	surgical	pathology	diagnosing	adenomyomatous	hyperplasia	(AH)Discussion•		Although	uncommon,	AH	should	be	considered	in	the	differential	of	CBD	dilatation•		Brush	cytology	may	be	suggestive	of	dysplasia	and	lead	to	surgical	resection•		Histology	will	show	multiple	lobules	of	glands	in	the	muscle	layers	of	the	ampulla	and	hypertrophy	of	the	sphincter	of	Oddi•		Gastroenterologists,	surgeons,	and	pathologists	should	be	aware	of	AH	of	the	ampulla	of	Vater	as	a	rare	benign	clinical	entity	which	may	mimic	a	pancreaticobiliary	malignancy Case PresentationEndoscopic ultrasound showing significant common bile duct dilatationPatient 1•		A	74	year-old	female	with	a	history	of	cholecystectomy	presents	with	recent	colonic	surgery	complicated	by	an	intra-abdominal	abscess•		CT	imaging:	incidental	dilatation	of	the	CBD	without	pancreatic	mass•		Endoscopic	ultrasound	(EUS)	and	endoscopic	retrograde	cholangiopancreatography	(ERCP):  -  Dilatation of the CBD to 18 mm down to the ampulla and pancreatic duct prominence of 3.5 mm by EUS  -  Cholangiogram: significant upstream CBD dilation and a 1 cm stricture of the distal CBD•		Patient	underwent	sphincterotomy,	cytology	brushings	of	the	distal	CBD,	and	biliary	stent	placement•		Brush	cytology:	malignant	adenocarcinoma•		Patient	underwent	pancreaticoduodenectomy•		Final	surgical	pathology:	AH	of	the	ampulla	of	Vater	and	incidental	focal	low-grade	pancreatic	intraepithelial	neoplasia•		Post-operative	course	has	been	uneventful	and	she	is	doing	wellCholangiogram performed during ERCP showing significant dilatation of the biliary system prior to intervention with a stentView of prominent ampulla of Vater through a duodenoscope after endoscopic intervention with biliary stent  Case PresentationEUS: significant common bile duct dilatation with suggestion of abrupt taperPatient 2•		A	73	year-old	female	with	a	history	of	cervical	carcinoma,	chronic	kidney	disease,	and	cholecystectomy	presents	with	epigastric	pain,	back	pain,	dark	urine,	and	weight	loss•		MRCP:	CBD	dilatation	to	20	mm•		EUS	and	ERCP	showed:  -  CBD dilatation to 20 mm (10 mm in the distal CBD) and a prominent pancreatic duct (3 mm)   -  Cholangiogram:  shelf in the CBD with abrupt tapering in the distal CBD•		Patient	underwent	sphincterotomy,	cytology	brushings	of	the	distal	CBD,	and	biliary	stenting•		Brush	cytology:	distal	CBD	high-grade	biliary	intraepithelial	neoplasia;	adenocarcinoma	could	not	be	excluded•		Patient	underwent	pancreaticoduodenectomy•		Final	surgical	pathology:	features	of	AH	of	the	ampulla	of	Vater	without	carcinoma•		Her	course	has	been	uneventful	after	post-operative	recoveryView of prominent ampulla of Vater through a duodenoscope prior to ERCPCholangiogram performed during ERCP showing significant dilatation of the intrahepatic and extrahepatic biliary system prior to intervention with a stentHistopathology Specimen After PancreaticoduodenectomyOrifice of papilla showing features of adenomatous hyperplasia: hyperplastic glandular lobules interspersed among smooth muscle bundles. Ampullary duodenal mucosa present at upper left corner, pancreas present at lower left corner. H and E, 20xHistopathology Specimen After PancreaticoduodenectomyBenign glandular lobule with cystic dilatation, surrounded by smooth muscle bundles. H and E,  100xHistopathology Specimen After PancreaticoduodenectomyDilated bile duct showing reactive epithelial atypia and acute inflammation. H and E, 200xLehigh Valley Health Network, Allentown, PAAdenomyomatous Hyperplasia of the Ampulla of Vater Masquerading as Malignancy: A Case SeriesPatrick Hickey DO, Saba Ahmad MD, Matthew Sullivan DO, Miriam Enriquez MD, Jeffrey Brodsky MD and Hiral Shah MD

Adenomyomatous Hyperplasia of the Ampulla of Vater Masquerading as Malignancy: A Case Series

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Adenomyomatous Hyperplasia of the Ampulla of Vater Masquerading as Malignancy: A Case Series

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