Presentation
Intermittent colicky RUQ pain. Suspected gallstones
Patient Data
CTIVC demonstrates a soft tissue density at the ampullary region extending into the distal CBD over a short distance, causing biliary obstruction. No stone disease.
An ill-defined ampullary mass is seen, measuring 1.6 x 1.6 x 2.2 cm. This is associated with increased distension of the intra and extra hepatic bile ducts, with the common bile duct measuring up to 17 mm in diameter. This has reduced from the pre-ERCP imaging, where the common bile duct measured at 22 mm in diameter. Intrahepatic pneumobilia is now present. There is pancreatic duct dilation, which measures up to 5 mm.
The lesion is well clear of the superior mesenteric vessels and portal vein. No further pancreatic lesions are identified.
An enlarged lymph node is seen in the porta hepatis, inferior to the neck of gallbladder, measuring 11 x 16 mm. No further abdominal or pelvic lymphadenopathy is demonstrated.
No focal liver lesions. 9 mm left renal cyst, otherwise the kidneys are unremarkable. No abnormality of the spleen, adrenals, bladder or bowel. The lung bases show minor atelectasis and incidental cysts. No airspace consolidation or lesions. No suspicious osseous lesions.
Conclusion:
Ampullary lesion, with biliary obstruction. The appearance is consistent with a pancreatic or ampullary carcinoma. Solitary borderline enlarged porta hepatis lymph node. No other evidence of regional or distant spread.
ERCP AND BIOPSY
CLINICAL NOTES:
Case Discussion
There are no features on imaging to indicate that this is a malignant lesion. Differential diagnosis would be between an adenoma and adenocarcinoma primarily.