Ampullary Tumors

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Ampullary tumor or ampullary carcinoma as it is commonly known is a benign or malignant formation in the ampulla of Vater. The ampulla of Vater or hepatopancreatic ampulla is a duct that is present as a union of the last centimetre of the pancreatic duct or the common bile duct. The ampulla of Vater protrudes into duodenum where all the pancreatic and biliary secretions enter the duodenum. When a tumor blocks the ampulla of Vater, the drainage of the biliary and pancreatic secretions are also blocked into the intestine. This can cause obstructive jaundice because the bile secretions mingle with the blood stream instead of passing into the intestine. Ampullary cancer is relatively very rare.

Causes

  • K-ras genetic mutations
  • Mutations in tumor suppressor genes p53 DPC4/SMAD4
  • Chromosome 17p and 18q – loss of heterozygosity
  • Familial adenomatous polyposis – FAP
  • Smoking
  • Diabetes mellitus

Symptoms

  • Progressive jaundice
  • Loss of appetite
  • Progressive weight loss – anorexia
  • Abdominal pain and back pain – back pain is an indication of advanced stages of cancer
  • Pruritus
  • Dyspepsia and vomiting – in case of damage to the duodenal lumen
  • Diarrhea – due to lack of lipase in the gut due to pancreatic duct obstruction
  • Gastrointestinal bleeding
  • Acute pancreatitis
  • Courvoisier’s law –  distended and  Palpable gall bladder

Diagnosis

Electrolyte panel measures the level of electrolytes and carbon-dioxide in the blood.

Complete blood count or CBC evaluates white blood cells, hemoglobin, hematocrit and red blood cells.

Liver function studies measures bilirubin direct and indirect transaminases, prothrombin time and alkaline phosphatase.

CA 19-9 is a serum tumor marker which often shows elevated pancreatic malignancies and is helpful in predicting tumor recurrence.

Abdominal ultrasonography and CT scan of the abdomen and pelvis help in revealing any metastatic disease in the regional lymph nodes, the liver and the areas of the pelvic region.

ERCP obtains evaluation of the ductal architecture.

EUS: Endoscopic ultrasound for diagnosis, biopsy and stenting.

Positron emission tomography or PET-CT scan can help detect metastases that can ideally be missed by any normal CT scan.

Treatment:

Endocscopic resection if it is a benign tumour. Whipple’s Pancreatico-duodenectomy if it is a malignant tumour, In patients who are not fit for surgery have a stent (fine tube) inserted which will help in facilitating bile flow and relieve jaundice.