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Biliary papillomatosis
BILIARY PAPILLOMATOSIS
A
B
C
D
A 52-year-old man was referred after endoscopic biliary stent insertion because of a diagnosis of ampullary cancer. He had complained of intermittent fever with chills and physical examination revealed mild right upper abdominal tenderness. Laboratory studies showed elevated serum bilirubin, alkaline phosphatase, and γ-glutamyl transpeptidase levels. Endoscopic retrograde cholangiography (A) disclosed diffusely dilated common bile duct (CBD) and common hepatic duct (CHD); the wall of the latter also had a ragged appearance. There was luminal narrowing and irregularities of the left intrahepatic duct (IHD). Duodenoscopy revealed a protruding mass with surface nodularity at the main duodenal papilla (B). A plastic stent was seen to emerge from the mass. Percutaneous transhepatic cholangioscopy (C) showed numerous papillary VOLUME 51, NO. 1, 2000
mucosal projections nearly obliterating the lumen in the left IHD. Papillary mucosal lesions were also noted in the distal CBD, CHD and right IHD. Biopsies of the left IHD (D) revealed well-differentiated papillary adenocarcinoma; those of the distal CBD, CHD and right IHD were papillary adenomas. Biopsies of the mass at the papilla revealed papillary adenocarcinoma. The final diagnosis was biliary papillomatosis with multifocal cancerous changes in the left IHD and at the main duodenal papilla. Radical resection of the entire papillary tumor was not possible and the patient underwent surgical curettage and hepaticojejunostomy. Dong Wan Seo, MD Sung Koo Lee, MD Myung Hwan Kim, MD Seoul, Korea GASTROINTESTINAL ENDOSCOPY
67
A
B
C
D
A 52-year-old man was referred after endoscopic biliary stent insertion because of a diagnosis of ampullary cancer. He had complained of intermittent fever with chills and physical examination revealed mild right upper abdominal tenderness. Laboratory studies showed elevated serum bilirubin, alkaline phosphatase, and γ-glutamyl transpeptidase levels. Endoscopic retrograde cholangiography (A) disclosed diffusely dilated common bile duct (CBD) and common hepatic duct (CHD); the wall of the latter also had a ragged appearance. There was luminal narrowing and irregularities of the left intrahepatic duct (IHD). Duodenoscopy revealed a protruding mass with surface nodularity at the main duodenal papilla (B). A plastic stent was seen to emerge from the mass. Percutaneous transhepatic cholangioscopy (C) showed numerous papillary VOLUME 51, NO. 1, 2000
mucosal projections nearly obliterating the lumen in the left IHD. Papillary mucosal lesions were also noted in the distal CBD, CHD and right IHD. Biopsies of the left IHD (D) revealed well-differentiated papillary adenocarcinoma; those of the distal CBD, CHD and right IHD were papillary adenomas. Biopsies of the mass at the papilla revealed papillary adenocarcinoma. The final diagnosis was biliary papillomatosis with multifocal cancerous changes in the left IHD and at the main duodenal papilla. Radical resection of the entire papillary tumor was not possible and the patient underwent surgical curettage and hepaticojejunostomy. Dong Wan Seo, MD Sung Koo Lee, MD Myung Hwan Kim, MD Seoul, Korea GASTROINTESTINAL ENDOSCOPY
67