Benign polyp of the ampulla of Vater.

Abstract

Benign tumors of the ampulla of Vater are rarely encountered in clinical practice but at least twenty symptomatic cases have been reported (1–19). Details of these cases are set forth in Table 1. The present case is apparently the second in which roentgenograms dearly revealed the lesion. Case Report A 54-year-old white woman was admitted to the Hospital of the University of Pennsylvania on Dec. 9, 1949, complaining of abdominal pain and jaundice for forty-eight hours. She gave a twenty-year history of upper abdominal complaints compatible with the diagnosis of gallbladder disease, and complained of increasing indigestion after meals in recent months. Two nights prior to admission she awoke with severe pain in the right upper quadrant of the abdomen, accompanied by vomiting, chills, and fever. Her physician reported jaundice. Her symptoms became worse during the next forty-eight hours and she was admitted to the hospital. Physical examination revealed a deeply jaundiced patient in obvious distress, with great tenderness in the right upper quadrant of the abdomen, where a rounded palpable mass was thought to be the gallbladder. The serum bilirubin was 3.5 mg. per 100 c.c. direct, and 6.1 mg. total; serum amylase 272 units. A single abdominal film did not show any opaque calculi in the region of the gallbladder. The following day, operation by Dr. 1. S. Ravdin revealed a huge, distended, edematous gallbladder. The common duct was 2 cm. in diameter and, although no stones were found, the possibility was entertained that a stone in the ampulla could have passed into the duodenum during the operative procedure. A cholecystectomy was performed and a T-tube was left in the common duct. Improvement was rapid. On Dec. 19, a cholangiogram revealed, at the duodenal end of the common duct, a filling defect which was interpreted as a gallstone (Fig. 1). Attempts were made to dissolve the stone, but the defect was again visualized when the cholangiogram was repeated on Dec. 30. The patient was discharged and readmitted one month later for re-exploration of the common duct. She had been feeling well in the interim. On Jan. 30, 1950, laparotomy revealed that the common duct was still greatly enlarged, but when it was opened, no stone was found. The duodenum was opened in its long axis and appeared normal. The ampulla of Vater was incised, and in its opening was a small polyp, which was excised. The wounds healed satisfactorily. Cholangiography was again done on Feb. 7, 1950, and the filling defect was no longer demonstrable. The pathological diagnosis was: “polyp (adenomatous type) of the papilla of Vater.” Discussion The true incidence of benign tumors in the ampulla of Vater is uncertain. Baggenstoss (20) found 4 polyps during the careful dissection of 100 ampullas. He also reported 25 benign polyps recorded as incidental findings at autopsy.