Ampullary Carcinoma Presenting as Gastrointestinal Bleeding

Abstract

Purpose: We report a 67 year old female that presented with melena and profound anemia that was found to have an actively bleeding ampullary adenocarcinoma by esophagogastruoduodenoscopy (EGD) with biopsy. Endoscopic ultrasound (EUS) was done for local regional staging which showed a T1N0 lesion. The CT of chest, abdomen and pelvis as well as bone scan showed no distant metastasis or lymphadenopathy. Patient, subsequently, underwent pancreaticoduodenectomy and obtained cure with clean surgical margins confirming the T1N0 ampullary adenocarcinoma. Ampullary adenocarcinoma is a malignant tumor arising from ampulla of vater, an anatomic opening of pancreatic and biliary ductal systems to the duodenum. Survival rates are more favorable than pancreatic cancer (1). The most common clinical presentation of ampullary cancer is obstructive jaundice although other symptoms such as weight loss, general malaise and depression are also seen (2). However, Ampullary cancer presenting initially with gastrointestinal bleeding as in our case is uncommon. Ampullary carcinoma accounts for a 0.2–1% of GI malignancies (1, 2). In general the 5-year survival rate is 39–50%. After pancreaticoduodenectomy five-year survival rates range from 64 to 80 percent for patients with T1N0 disease like our case. An early diagnosis was possible in part due to atypical presentation and rapid use of gastrointestinal procedures. This permited a prompt diagnosis, staging and curable treatment. Note that as in our case the EUS for local regional staging is critical prior to comtemplating surgical resection.Figure: Bleeding ampullary mass.Figure: Cessation of bleeding after aggressive washing.Figure: Ampullary mass.