Invaginated ampulla of Vater in synchronous malignant intraductal papillary mucinous neoplasm of the pancreas and common bile duct cancer

Abstract

A 61-year-old woman was admitted for upper abdominal pain and fever. Laboratory findings showed raised neutrophil ratio and amylase and lipase levels. Abdominal computed tomography (CT) scan revealed diffuse swelling of the pancreas with peripancreatic fluid, and mild dilatation of the mid-pancreatic duct. Endoscopic retrograde cholangiopancreatography (ERCP) showed dimpling of the ampullary orifice ([Fig. 1]). We inserted an endoscopic retrograde pancreatic drain (ERPD) via a guide wire. A pancreatogram showed pancreatic duct dilatation and deformity ([Fig. 2]) and due to stricture of the pancreatic duct orifice, the ERPD required repositioning. During removal of the ERPD for repositioning, the ampullary orifice, which was invaginated, protruded into the duodenal lumen ([Fig. 3]). A biopsy specimen was taken from the invaginated ampullary orifice, and confirmed to be adenocarcinoma. The patient underwent pylorus-preserving pancreaticoduodenectomy. The postoperative pathology report confirmed the diagnosis of a double primary tumor: the first tumor being a malignant intraductal papillary mucinous neoplasm (IPMN) of the pancreas and the other an adenocarcinoma of the common bile duct (CBD). Histologic exam documented anomalous union of pancreaticobiliary duct with short segment common channel and separated incidental IPMN of main duct in pancreas head. Protruded mass of ampulla of Vater was confirmed as CBD originated.