Leiomyoma of the major papilla

Abstract

A 78-year-old woman presented with jaundice and fever of 3 days' duration. The sclerae were icteric and tenderness was elicited on palpation of the abdomen in the epigastrium and right upper quadrant. Laboratory test results were as follows: white blood cell count, 16.0 × 10(3)/UL (normal: 7-10 × 10(3)/UL); hemoglobin, 10.2 g/dL (12.5-15 g/dL); aspartate aminotransferase, 80 U/L (10-35 U/L); alanine aminotransferase, 54 U/L (0-40 U/L); alkaline phosphatase, 352 U/L (66-240 U/L); total bilirubin, 3.8 mg/dL (0-1 mg/dL); and direct bilirubin, 2.5 mg/dL (0-1 mg/dL). Transabdominal US revealed a dilated bile duct with gallstones and gallbladder distension with thickening of the wall and gallstones. At duodenoscopy there was a huge submucosal mass at the major papilla (A). Although the orifice of the papilla was widely patent (A), cannulation was unsuccessful because of contact bleeding. Percutaneous transhepatic biliary and gallbladder drainage was performed at which cholangiography demonstrated multiple filling defects in the bile duct and a stricture involving the distal common bile duct. In addition, a crescent-shaped structure was outlined in the region of the papilla (B). Transhepatic intraductal US demonstrated a heterogeneous, hypoechoic tumor (2.5 × 3.1 cm) arising from the muscularis propria of the papilla (C). A pylorus-preserving pancreaticoduodenectomy was performed and histopathologic examination of the resection specimen disclosed spindle-shaped cells with elongated nuclei without mitotic figures (D; H&E, orig. mag. ×400). The lesion was localized to the muscularis propria and there was a small mucosal ulceration. These findings confirmed the diagnosis of leiomyoma of the major duodenal papilla