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Intussuscepting Ampullary Adenoma: An Unusual Cause of Gastric Outlet Obstruction Leading to Cavitating Lung Lesions

View Article: PubMed Central - PubMed

ABSTRACT

Ampullary adenomas are a rare clinical entity, occurring at a rate of 0.04–0.12% in the general population. They are premalignant lesions which have the capability to progress to malignancy, and they should be excised if they are causing immediate symptoms and/or are likely to degenerate to carcinoma. Intestinal intussusception in adults is rare and, unlike in children, is often due to a structural pathology. Intussuscepting duodenal/ampullary adenomas have been reported in the literature on 13 previous occasions, however never before with this presentation. We report the case of a woman who presented with a 1-year history of recurrent chest infections. She was treated with numerous antibiotics, whilst intermittent symptoms of recurrent vomiting and weight loss were initially attributed to her lung infections. A chest CT demonstrated multiple cavitating lung lesions, whilst an obstructing polypoid mass was noted at D2 on dedicated abdominal imaging. Due to ongoing nutritional problems, she had a semi-urgent pancreaticoduodenectomy. Intraoperative findings demonstrated a large mass at D2 with a duodeno-duodenal intussusception. Histological analysis reported a duodenal, ampullary, low-grade tubular adenoma, 75 × 28 × 30 mm in size, with intussusception and complete resection margins. The patient recovered well and was discharged on postoperative day 10, with no complications to date. Ampullary adenomas may present with obstruction of the main gastrointestinal tract and/or biliary/pancreatic ducts. Common presentations include gastric outlet obstruction, gastrointestinal bleeding or acute pancreatitis. This unique presentation should remind clinicians of the need to investigate recurrent chest infections for a possible gastrointestinal cause.

No MeSH data available.


Related in: MedlinePlus

a External surface demonstrating intussuscepting duodenal ampullary tubular adenoma. The black arrow indicates the site of invagination. b Luminal surface. The white arrow indicates the circumferential duodenal ampullary tubular adenoma. c HE. ×5 magnification. Tubular adenoma. d HE. ×100 magnification. Tubular adenoma with low-grade dysplasia.
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Figure 3: a External surface demonstrating intussuscepting duodenal ampullary tubular adenoma. The black arrow indicates the site of invagination. b Luminal surface. The white arrow indicates the circumferential duodenal ampullary tubular adenoma. c HE. ×5 magnification. Tubular adenoma. d HE. ×100 magnification. Tubular adenoma with low-grade dysplasia.

Mentions: Intraoperatively, a large mass at D2 with a duodeno-duodenal intussusception and distal duodenal ischaemia was identified (fig 3). Histological analysis reported a polypoid tumour at the Ampulla of Vater, 75 × 28 × 30 mm in size, with a reduced intussusception and an ischaemic distal duodenum (fig 3). These findings were in keeping with a duodenal ampullary low-grade tubular adenoma, with intussusception and complete resection margins. There was no evidence of any high-grade dysplasia, in contrast to her previous diagnostic biopsy, or invasive malignancy. The patient was admitted to the high-dependency unit postoperatively and was stepped down to the surgical ward on postoperative day 2. She progressed well with early mobilisation, and her nutritional status greatly improved during this time, with due care not to induce a refeeding syndrome. She was medically stable and deemed fit for discharge on postoperative day 10. She resumed work 4 weeks postoperatively, with no evidence of recurrent chest infections. She did not develop any exocrine pancreatic insufficiency or any derangement from her baseline glycaemic control. To date, the patient has not suffered any long-term complications, and remains clinically well on follow-up.


Intussuscepting Ampullary Adenoma: An Unusual Cause of Gastric Outlet Obstruction Leading to Cavitating Lung Lesions
a External surface demonstrating intussuscepting duodenal ampullary tubular adenoma. The black arrow indicates the site of invagination. b Luminal surface. The white arrow indicates the circumferential duodenal ampullary tubular adenoma. c HE. ×5 magnification. Tubular adenoma. d HE. ×100 magnification. Tubular adenoma with low-grade dysplasia.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5121554&req=5

Figure 3: a External surface demonstrating intussuscepting duodenal ampullary tubular adenoma. The black arrow indicates the site of invagination. b Luminal surface. The white arrow indicates the circumferential duodenal ampullary tubular adenoma. c HE. ×5 magnification. Tubular adenoma. d HE. ×100 magnification. Tubular adenoma with low-grade dysplasia.
Mentions: Intraoperatively, a large mass at D2 with a duodeno-duodenal intussusception and distal duodenal ischaemia was identified (fig 3). Histological analysis reported a polypoid tumour at the Ampulla of Vater, 75 × 28 × 30 mm in size, with a reduced intussusception and an ischaemic distal duodenum (fig 3). These findings were in keeping with a duodenal ampullary low-grade tubular adenoma, with intussusception and complete resection margins. There was no evidence of any high-grade dysplasia, in contrast to her previous diagnostic biopsy, or invasive malignancy. The patient was admitted to the high-dependency unit postoperatively and was stepped down to the surgical ward on postoperative day 2. She progressed well with early mobilisation, and her nutritional status greatly improved during this time, with due care not to induce a refeeding syndrome. She was medically stable and deemed fit for discharge on postoperative day 10. She resumed work 4 weeks postoperatively, with no evidence of recurrent chest infections. She did not develop any exocrine pancreatic insufficiency or any derangement from her baseline glycaemic control. To date, the patient has not suffered any long-term complications, and remains clinically well on follow-up.

View Article: PubMed Central - PubMed

ABSTRACT

Ampullary adenomas are a rare clinical entity, occurring at a rate of 0.04–0.12% in the general population. They are premalignant lesions which have the capability to progress to malignancy, and they should be excised if they are causing immediate symptoms and/or are likely to degenerate to carcinoma. Intestinal intussusception in adults is rare and, unlike in children, is often due to a structural pathology. Intussuscepting duodenal/ampullary adenomas have been reported in the literature on 13 previous occasions, however never before with this presentation. We report the case of a woman who presented with a 1-year history of recurrent chest infections. She was treated with numerous antibiotics, whilst intermittent symptoms of recurrent vomiting and weight loss were initially attributed to her lung infections. A chest CT demonstrated multiple cavitating lung lesions, whilst an obstructing polypoid mass was noted at D2 on dedicated abdominal imaging. Due to ongoing nutritional problems, she had a semi-urgent pancreaticoduodenectomy. Intraoperative findings demonstrated a large mass at D2 with a duodeno-duodenal intussusception. Histological analysis reported a duodenal, ampullary, low-grade tubular adenoma, 75 × 28 × 30 mm in size, with intussusception and complete resection margins. The patient recovered well and was discharged on postoperative day 10, with no complications to date. Ampullary adenomas may present with obstruction of the main gastrointestinal tract and/or biliary/pancreatic ducts. Common presentations include gastric outlet obstruction, gastrointestinal bleeding or acute pancreatitis. This unique presentation should remind clinicians of the need to investigate recurrent chest infections for a possible gastrointestinal cause.

No MeSH data available.


Related in: MedlinePlus