Roentgenographic Diagnosis of Neoplasms of the Peri-Ampullary Region and Head of the Pancreas

Abstract

Radical excision of carcinoma of the ampulla of Vater and of the head of the pancreas, together with the entire duodenum, is feasible (Diagram 1). For this reason there should be increased interest in the radiographic diagnosis of neoplasms in these regions. Peri-ampullar lesions should be more readily detected than carcinomas in the head of the pancreas, since the latter, especially in the operable stage, may not produce changes in the duodenal wall or contour of the duodenal curvature. The term “ampullar carcinoma” is commonly employed to designate neoplasms of the true ampulla as well as those arising from the papilla of Vater or immediate vicinity. Ampullar carcinomas may be polypoid and protrude into the duodenal lumen. When large, they are readily observed. Such an example is shown in Figure 1. This carcinoma was resected transduodenally, with reimplantation of bile and pancreatic ducts and the patient remains well five years later, a roentgenogram now affording practically a normal picture of the duodenum. A neoplasm arising within the ampulla expands the latter, affording the appearance of a smooth enlarged papilla of Vater. Theoretically this should be easily demonstrable but inability to produce marked distention of the duodenum by barium probably accounts for frequent failure of detection at fluoroscopy. The surgical specimen shown in Figure 2, consisting of the entire duodenum and the head of the pancreas, resected for ampullar carcinoma extending up the common duct, shows an enlarged and prominent papilla which was not discovered on fluoroscopy. A roentgenogram made three months after operation, as depicted in Diagram 1, shows the disposition of barium in the altered upper alimentary tract (Fig. 2B). Ampullar carcinomas may also afford flattened ulcerations with raised rolled edges (Fig. 3A). These may produce consistent irregularities in outline of the duodenal wall accentuated by a stiffness of the involved segment (Fig. 3B). Extensive infiltration of the duodenal wall by ampullar carcinoma, or carcinoma primary in the second portion of the duodenum, causes great distortion of the wall and rigidity of the involved segment, and should be easily detected. In these cases, also, normal mucosal markings are replaced by irregular coarse markings and there may be polypoid masses protruding into the lumen.