Ampullectomy as Treatment for Severe Anemia

Abstract

FigureIntroduction: Duodenal polyps are an uncommon finding on upper endoscopy. Ampullectomy is performed by pancreatico-biliary endoscopists typically to resect premalignant lesions of the major papilla. However, inflammatory polyps of the ampulla that present with severe gastrointestinal bleeding are quite rare. Methods: Video case report of a patient who underwent ampullectomy for endoscopic treatment of severe anemia. Results: A 50-year-old woman presented with one month of fatigue and dyspnea. She had a hemoglobin of 8.8 g/dL, which was down from a baseline value of 12 g/dL. She was transfused 2 units of packed red blood cells and underwent upper endoscopy (EGD) locally. EGD revealed a nodular, fingerlike projection that arose from the ampulla and oozed blood. She was transferred to our institution for endoscopic therapy. Upon arrival, her hemoglobin was 7 g/dL. She was hemodynamically compromised and required additional transfusions. After hemodynamic stabilization, further endoscopic diagnosis and therapy were pursued. EGD confirmed a fingerlike lesion in the second portion of the duodenum which was actively bleeding. Endoscopic ultrasound demonstrated a villous projection at the ampulla that measured 9 mm by 3 mm, had well-defined borders, and no invasion into the submucosa or muscularis propria. Color flow and doppler ultrasound identified a vessel within the lesion. Duodenoscopy revealed a 1-cm lesion projecting from the superior portion of the ampulla that was bleeding. Endoscopic retrograde cholangiopancreatography was performed and a cholangiogram did not demonstrate any intraductal invasion or abnormalities. Resection of the ampullary lesion was pursued to treat her life-threatening bleeding. Submucosal lifting of the ampulla was performed by injecting epinephrine (1:10,000) diluted in normal saline. The ampullary lesion was removed en bloc using a hot snare and coagulation current. Biliary and pancreatic sphincterotomies were performed, and a 5 Fr x 4 cm plastic stent was placed into the ventral pancreatic duct to reduce the risk of pancreatitis. Following ampullectomy, the patient's bleeding ceased and her hemoglobin normalized. Pathology revealed a non-dysplastic inflammatory polyp. Follow-up EGD 4 months after ampullectomy demonstrated no evidence of ampullary recurrence or abnormality. Conclusion: Bleeding is a known complication of ampullectomy. However, ampullectomy as treatment for life-threatening bleeding from a non-dysplastic inflammatory polyp is exceedingly rare.