2149 Successful Stenting of the Common Bile Duct Through an Ectopic Ampulla of Vater in the Pylorus

Abstract

INTRODUCTION: The ampulla of Vater comprises the choledochopancreatic junction and sphincter of Oddi, traversing the posteromedial wall of the descending duodenum via the major papilla. Ectopic gastric ampullae are rare, and since the 16th century, pyloric ampullae of Vater are only documented in a handful of case reports 1 . We present a case of an extremely rare ectopic ampulla of Vater in the pylorus through which successful stenting of the common bile duct (CBD) was performed during ERCP. CASE DESCRIPTION/METHODS: A 51-year-old man presented with nausea, vomiting, and midepigastric pain radiating to the back. He was tachycardic to 117 bpm with right upper quadrant tenderness on exam. Labs showed WBC 13.5 × 109/L, AST 123 IU/L, ALT 186 IU/L, ALP 722 IU/L, lipase of 195 IU/L, and total bilirubin of 3.1 mg/dL. Contrast CT revealed a distended gallbladder with wall thickening and pericholecystic fluid, intrahepatic and extrahepatic biliary dilatation, and calcified CBD stones with pancreatic duct dilatation. Ultrasound confirmed a sonographic Murphy sign and a 9 mm CBD. After receiving intravenous ciprofloxacin and metronidazole, he underwent ERCP. Initial attempts to locate the ampulla in the duodenum were unsuccessful with a side-viewing scope. Eventual use of a forward-viewing scope identified the ampulla and a clean based ulcer in the pylorus. Purulent drainage was observed following sphincterotomy and balloon extraction. A 7 French x 5 cm stent was carefully deployed in the CBD. Prior to discharge, the patient underwent uncomplicated laparoscopic cholecystectomy. Stent was successfully retrieved 6 weeks later, again using the forward-viewing scope. Biopsies of the ampulla and ulcer confirmed acute and chronic gastritis negative for H. pylori or malignancy. DISCUSSION: As in the present case, literature suggests a recurrent triad of choledocholithiasis, cholangitis, and ulcer disease, perhaps due to reflux of gastric secretions into the hepatobiliary tree and increased mucosal exposure to pancreaticobiliary secretions. To the authors’ knowledge, this case possibly represents the first successful stenting of the CBD through an ectopic ampulla of Vater in the pylorus, proving that this can be a safe and effective option. Gastroenterologists should be aware of ectopic anatomy when the ampulla cannot be located in the duodenum.