Bulging of the major duodenal papilla

Han Taek Jeong; Jimin Han

doi:10.5946/ce.2024.141

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Boost Your Learning with Quiz Bulging of the major duodenal papilla: Han Taek Jeong, Jimin Han^,; DOI: https://doi.org/10.5946/ce.2024.141
Published online: September 6, 2024

Division of Gastroenterology, Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu, Korea

Correspondence: Jimin Han Division of Gastroenterology, Department of Internal Medicine, Daegu Catholic University School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea E-mail: jmhan@cu.ac.kr

• Received: May 30, 2024 • Revised: June 16, 2024 • Accepted: June 17, 2024

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Quiz

A 76-year-old woman presented with upper abdominal pain of sudden onset. She had a history of hepatitis B virus-related liver cirrhosis, had been taking tenofovir for two years, and had no fever. An abdominal examination revealed tenderness without rebound in the right upper quadrant. The results of blood tests were as follows: white cell count 10,000/mm³, hemoglobin 13.5 g/dL, aspartate aminotransferase 331 IU/L, alanine aminotransferase 106 IU/L, alkaline phosphatase 106 IU/L, gamma glutamyl peptidase 183 U/L, total bilirubin 1.4 mg/dL, and direct bilirubin 0.5 mg/dL. Serum amylase and lipase levels were within normal ranges. Abdominal computed tomography showed slight dilatation of the common bile duct and a 1.4 cm cystic mass at the ampullary level (Fig. 1A). The initial endoscopic retrograde cholangiopancreatography (ERCP) demonstrated smooth bulging of the major duodenal papilla (Fig. 1B, C). Deep bile duct cannulation failed, and a 5 Fr 3 cm pancreatic stent was placed (Geenen Pancreatic Stent; Cook Medical LLC) because of the repeated pancreatic duct cannulation. The second attempt at ERCP showed persistent bulging of the major duodenal papilla (Fig. 1D). Bile duct cannulation was successful after needle-knife infundibulotomy (Fig. 1E), and cholangiography revealed saccular dilatation and contrast retention at the ampullary level (Fig. 1F). Biliary stenting with a 7 Fr 5 cm stent (C-Flex Double Pigtail Biliary Stent; Boston Scientific Corporation) was performed. The patient was discharged without complications.

What is the most likely diagnosis?

Answer

The diagnosis was choledochocele. After two weeks, the biliary and pancreatic stents were removed. The bulging of the major duodenal papilla had deflated. Since then for approximately three years, the patient has been asymptomatic and has been uneventfully undergoing follow-up for liver cirrhosis.

Choledochocele is an uncommon congenital malformation of the biliary tract and is classified as a Type III choledochal cyst according to the Todani system.¹ The pathogenesis of choledochocele has not yet been elucidated.² The clinical manifestations vary; upper abdominal pain with nausea and vomiting is the most common presenting symptom.² Acute pancreatitis, stone formation within the cystic dilatation, jaundice, and cholangitis have also been described.² Malignancy of the Ampulla of Vater and bile duct has been reported only in adults³^,⁴ The estimated incidence of malignancy in choledochocele is approximately 2.5%,² which is much lower than that of the other types of choledochal cysts. ERCP is the most widely used method for the diagnosis and concomitant treatment of choledochocele.² During endoscopic examination, the choledochocele is seen as a smooth round protrusion of the major duodenal papilla. The overlying mucosal surface is soft on palpation. With contrast injection into the bile duct, enlargement of the choledochocele develops and the retention of the contrast inside the cystic dilatation is seen. Endoscopic therapy is considered the standard of care in most patients with symptomatic choledochocele given the low risk of malignancy in choledochocele.² Endoscopic sphincterotomy is usually used, but endoscopic snare resection of the choledochocele has been reported.² There are no established recommendations for surveillance after endoscopic therapy. However, the need for surveillance to detect biliary tract cancer should be discussed with the patient.

Conflicts of Interest

Jimin Han is currently serving on the KSGE Publication Committee; however, Jimin Han was not involved in the peer reviewer selection, evaluation, or decision process for this article. Han Taek Jeong has no potential conflicts of interest to declare.

Funding

None.

Fig. 1.

(A) Abdominal computed tomography showed a 1.4 cm cystic mass (asterisk) at the ampullary level. (B) Initial endoscopic retrograde cholangiopancreatography demonstrated smooth bulging of the major duodenal papilla. (C) Type III periampullary diverticulum was noted. Orifice was well seen. (D) Second endoscopic retrograde cholangiopancreatography showed persistent bulging of the major duodenal papilla. (E) Deep bile duct cannulation was successful after infundibulotomy. (F) Cholangiography showed saccular dilatation at the ampullary level.

REFERENCES

1. Todani T, Watanabe Y, Narusue M, et al. Congenital bile duct cysts: classification, operative procedures, and review of thirty-seven cases including cancer arising from choledochal cyst. Am J Surg 1977;134:263–269.Article PubMed
2. Law R, Topazian M. Diagnosis and treatment of choledochoceles. Clin Gastroenterol Hepatol 2014;12:196–203.Article PubMed
3. Lobeck IN, Dupree P, Falcone RA Jr, et al. The presentation and management of choledochocele (type III choledochal cyst): A 40-year systematic review of the literature. J Pediatr Surg 2017;52:644–649.Article PubMed
4. Lee DH, Kim JS, Kim JH, et al. A case of choledochocele associated with papillary adenocarcinoma. Clin Endosc 2007;35:364–368.

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Bulging of the major duodenal papilla

DOI: https://doi.org/10.5946/ce.2024.141

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Figure

Bulging of the major duodenal papilla

Fig. 1. (A) Abdominal computed tomography showed a 1.4 cm cystic mass (asterisk) at the ampullary level. (B) Initial endoscopic retrograde cholangiopancreatography demonstrated smooth bulging of the major duodenal papilla. (C) Type III periampullary diverticulum was noted. Orifice was well seen. (D) Second endoscopic retrograde cholangiopancreatography showed persistent bulging of the major duodenal papilla. (E) Deep bile duct cannulation was successful after infundibulotomy. (F) Cholangiography showed saccular dilatation at the ampullary level.

Fig. 1.

Bulging of the major duodenal papilla