Diapositive 1

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GI8
IMAGING AMPULLOMA OF VATERS PAPILLE
SERIES OF FIFTEEN CASES
YAHDI VICHE, R SAOUAB, J EL FENNI, S. CHAOUIR, T.
AMIL, A HANINE, B RADOUANE
Radiology Service Instruction
Military Hospital Mohammed V
In collaboration with the
visceral surgery service (Sair Pr)
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INTRODUCTION

• The ampullomas vatériens often malignant or
  benign tumors derived from the intersection area
  bounded by biliopancreatic tract and the
  sphincter of Oddi (the last 2cm of the
  biliopancreatic junction)
• Biliary obstruction is early clinical symptoms
• The cross-sectional imaging is a great
  contribution to the diagnosis, staging and
  monitoring
• Early diagnosed , the prognosis is better than
  pancreatic cancer

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OBJECTIVES

• To report the clinical and epidemiological
  aspects of ampullomas vatériens in the series.
• Establish the role and limitations of each
  imaging system.
• Describe aspects of imaging ampullomas
  vatériens.
• Discuss the differential diagnosis.

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Materials and Methods

• Retrospective review of records of ampullomas
  vatériens explored in the training.
• During 6 years period January 2005 - December
  2010.
• The image system used
• - Ultrasound (n 15)
• - CT (n 11)
• - MRI (n 4)
• - Endoscopic retrograde cholangiography (n 4).

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RESULTS

• 15 cases of ampulla vatériens were detected
• Their representation are
• - 0.2 of hospitalizations in the department of
  visceral surgery
• - 3.4 of digestive cancers (rank 8)
• Average age 68 years Between 52ans and 89ans
• 9 Males and 6 Female

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RESULTS
The clinical symptoms were mostly dominated by
cholestatic jaundice
Cholestatic Jaundice 100 Disorders of
transit 46 AEG 66.60 Abdominal pain
40 Fever 13 Melaena 26.60
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RESULTS
Ultrasound Imaging
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RESULTS
CT Imaging

• The ampullary tumor was detected in 6 cases
• - Process hypodense bulging through the duodenal
  wall 4 patients (36.3)
• - Barrier tissue density of the lower bile duct
  2 patients (16.6).
• Flooding pancreas 2 cases
• Lymph node metastasis 2 cases
• Visceral metastases 1 patient

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RESULTS
Case 1 Abdominal CT in axial(a), Reconstruction
with frontal (b), C Tissue process of
duodenal papilla, enhanced homogeneously, causing
a dilation of a EHBD.
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RESULTS
Case 2 Abdominal CT in axial, C Dilatation
of intrahepatic bile ducts and extrahepatic
upstream of a process of lower bile duct tissue
coming in contact with the posterior wall of D3
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RESULTS
Case 3 40 years old man, obstructive
jaundice Abdominal CT in axial, C-(a, c) / C
(b, d) Tissue mass of the pancreatic duodena's
block, is moderately enhancing after injection of
Pc and invading the pancreatic head, and he joins
in a slight bile duct dilatation (d). ADK poorly
differentiated ampullary
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RESULTS
Case 3 one year later Increasing the size of
the process with ampullary appearance of liver
metastases
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RESULTS
Case 4 62 year old man obstructive jaundice
GI bleeding Abdominal CT in axial, C-(a, c) / C
Large mass enhanced after injection, bulging
into the duodenal lumen and invading the
biliopancreatic junction (arrow) with dilatation
of upstream bicanalaire (arrow heads)
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RESULTS
MRI Imaging

• The ampullary tumor was mentioned in 3 cases

Dilatation of the CBD and upstream IHBD a
circumferential thickening with stenosis of the
lower bile regularly. The main pancreatic duct is
not dilated
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RESULTS
endoscopy
histology
Adenocarcinoma in all cases
CPD 9 cases (Cephalic pancreato-duodenectomy)
Surgery bypass 5 cases
Endoscopic bypass 1 case
evolution
Death 2 cases (5 to J and J 10) Tumor
recurrence a case (15 months)
Death 3 cases (5 months, 6 months and 9
months)
Death at 4 month
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DISCUSSION
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Anatomy
1. Choledocho-wirsungo-duodenal junction and
sphincter of Oddi Headquarters
middle part of D2 at the junction of the
posterior and inner surfaces Variations Low
set, sometimes at D3 The lower part of channels
is surrounded by the sphincter of Oddi. This
block sphincter is located at a true dehiscence
of the duodenal wall the "duodenal window." The
posterior part is low Frequency diverticulum at
this level
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ANATOMY
1. Choledocho-wirsungo -duodenal junction
and sphincter of Oddi The system terminal
pancreatic duct is less and ventral to the common
bile duct The type of anastomosis of the two
channels is variable common channel (60)
gunmetal at the top of the papilla (38)
separate duodenal anastomosis (2)
RadioGraphics 2002 Volume 22 ? Number 6
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Anatomy
2.The pancreatic duodenal block The pancreas
with its reports (after L. Testut, Human
Anatomy). A, pancreas, has with his head, and
B, duodenum, C, jejunum, D, gallbladder 1,
pancreatic duct, 2, accessory pancreatic duct,
the arrow indicates its opening in 2 ', on the
posteromedial wall of the duodenum, 3, ampullary,
6, hepatic duct, 7, aorta 8, mesenteric vessels
higher 9, celiac trunk with three branches.
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Epidemiology
The ampullary vatérien is a rare tumor 0.02 to
5 of gastrointestinal tumors Peak age between
50 and 70 years with slight male
predominance Predisposing factors
Familial adenomatous polyposis (ampullary adenoma
in 50 of cases) Gardner's syndrome
Van Recklinghausen's disease The association
with cholelithiasis is found in 8-20 depending
on the series
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Pathology
The region tumors vatérienne can develop from
the bulb itself or from the duodenal mucosa,
pancreas and bladder. Gross pathology two types
of developmentIntra-duodenal (2/3 of cases) the
tumor may be polypoid or vegetative (30),
submucosal (26) or ulcerated Intra-papillary
(1/3 of cases) strictly localized to the ampulla
of Vater Microscopy ampullary tumors are
malignant in 95 of cases dominated by
adenocarcinomas
Sprouting aspect of the papilla at endoscopy
performed in one patient in our series
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Pathology
TNM Classification UICC 2002
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PATHOLOGICAL ANATOMY
TNM Classification UICC 2002
T1 (a)Tm limited to the ampulla of Vater or
sphincter of Oddi T2 (b)Tm invading the
duodenal wall T3 (c)Tm invading the pancreas 2
cm or less Q4 (d)Tm invading the pancreas more
than 2 cm and / or adjacent organs
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Clinical
The obstructive jaundice it is the sign most
frequently revealing and often constant, found in
70-80 of cases GI bleeding Sx evocative but
inconstant (6 of cases), melaena, anemia Other
abdominal pain, transit disorders, IGC
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Imagery
1.Échographie
Review of first-line before a cholestatic
jaundice Interest Confirm the dilated bile
ducts in 100 of cases with hydrocholecyste
Specify the level of obstruction in 90 of cases
View ampullary tumor in 25 of cases
especially if the tumor sizegt 2 cm To
identify liver metastases Limits Tumors lt2
cm The nodal The interposition gas or
obesity
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Imagery
2.Echoendoscopie
Technical Use of a transducer rotating
scanning high frequency. In recent years,
development of mini probes of 2 mm diameter and
high frequency (20MHz) ? Possibility of
retrograde catheterization of the bile and
pancreatic ducts and Possible distinction between
the sphincter of Oddi and duodenal mucosa in NB
the risk of nodal involvement is zero in case of
tumors limited to the sphincter Mini probe
intra ductal (1 sphincter of Oddi).
Mini probe intra ductal (1 sphincter of Oddi).
NB the risk of nodal involvement is zero in case
of tumors limited to the sphincter
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Imagery
2.Echoendoscopie
Interest The visualization of the tumor
vatérienne in 90 to 100 of cases Superior
sensitivity than other imaging techniques for
evaluation of - The extension of the tumor (T)
if malignancy crossing the fourth hypoechoic
layer of the duodenal wall (muscularis) - The
nodal (N) diagnostic accuracy of 68 to 76 for
stage N1 - The invasion of the vein axis
mesocaval door with a sensitivity of 91 and a
specificity of 97 Indications Suspicion of
pathology with an ampullary OGDF a
cross-sectional imaging and inconclusive
Assessment of preoperative extension of ampullary
tumors proven choice of TRT (surgical
or endoscopic)
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Imagery
3.TDM
Importance Sensitivity of 85 to 90 in case of
biliary dilatation and specificity of
90. Technical Acquisition helical thin
sections Ingestion of water Study with and
without injection of the PC in arterial and
portal venous phase (with 100cc flow
3cc/sec) Results Positive diagnosis Turgid
appearance of the papilla or hypodense
heterogeneous process bulging into the duodenal
lumen The dilated bile ducts inside and outside
the liver associated with dilatation of the
pancreatic duct is highly suggestive of the
diagnosis Extension The pancreas, lymph node,
peritoneal or hepatic vein thrombosis
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Imagery
MRI
Interest better contrast resolution and multi
planar study Technical morphological
sequences axial acquisitions SPT1 and FAT-SAT
GADO T1, T2 Sp coronal acquisition, 4mm thick
Sequence diffusion and Bili-sequence MRI
Results MRI allows visualization of the
ampullary tumor in 93 of cases Small
polypoid lesion, iso or hypo T1 and T2, weakly or
moderately enhanced after injection protruding
into the duodenal lumen Sometimes, a simple
engorgement of the papilla Irregular
thickening of the biliopancreatic junction
The bili-MRI appreciate the topography and the
length of the obstacle. Frank said in a ruling
"pellet shells" referred to the diagnosis.
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Imagery
5. Other
a. UGI
Images evocative The gap tumor protruding into
the duodenal lumen.The classic image epsilon
(sign Frosberg or "reverse 3") ulceration within
a tumor proliferation. Images nonspecific The
irregular stenosis of the duodenum by discussing
the second duodenal cancer Expansion of the
duodenum Printing bulbar post a bile duct
dilatation
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Imagery
5.Other
b. Cholangiographie Retrograde Endoscopic (ERCP)
It allows To objectify stricture or bile duct or
ampullary gap in intra papillary forms that go
unnoticed at duodenoscopy. To complete the review
by a wirsungographie possible.
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Differential Diagnosis
Neoplastic causes Cancer of the pancreas head
The lower bile duct Cholangiocarcinoma
Cancer duodenal Non-neoplastic causes
Lithiasis of the CBD Barrier parasite cyst,
roundworms or flukes. Sclerosing
cholangitis Pancreatitis Inflammatory
stenosis of the bile duct. Sphincter of Oddi
dysfunction about 5 of patients suspected of
having a DSO have an ampullary Diverticulum
juxta-ampullary lithiasis and thus promotes
misdiagnosis. Benign papilla papilla 'forced'
migration after gallstone.
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Differential Diagnosis
1.Cancers peri-ampullary
a. Carcinome pancreatic pancreatic mass
hypovascular, often with an infiltrative lymph
node status. The expansion bicanalaire qq with
special featuresSx of four segments
visualization of biliopancreatic channels
upstream and downstream of the tumor The
pancreatic duct dilatation secondary
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Differential Diagnosis
1.Cancers peri-ampullary
b. Cholangiocarcinome Irregular thickening of
the bile duct wall or intraluminal polypoid mass
The distal common bile duct is often visible
sign 3 segments (2 segments of the bile duct
pancreatic duct non-dilated)
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Differential Diagnosis
1.Cancers peri-ampullary
c) duodenal Cancers Uncommon tumor It can
be polypoid, ulcerated or infiltrative Lymph
Nodes in 22-71 of cases The duct dilatation
biliopancreatic is moderate or absent
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Differential Diagnosis
2. Papillary inflammation
Multiple causes passage gallstones,
cholangitis, pancreatitis or acute infectious
(parasitic) Swollen appearance of the papilla
with homogeneous enhancement
3. Tumeur intra ductal papillary mucinous
pancreas (IPMT)
Papillary epithelial proliferation, benign or
malignant mucin-producing ductal dilatation
Peak age of 60 years with male predominance
Imaging papilla large (gt 10 mm) with multicystic
dilatation of the pancreatic duct and mural
nodules
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Differential Diagnosis
4. Other choledochal cyst

Intraoperative view after a duodenotomy
cholédochocèle, the ampullary ? vatérien
Subsidence choledochal cyst after dilation
of the papilla.
(Iconography of surgery visceral I)
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Treatment
The treatment of choice remains wide surgical
excision CPD type (cephalic pancreatico-duodenecto
my) unless otherwise-cons Vascular
invasion. Remote node metastases (lt5)
Métastases liver (5-10) Peritoneal
carcinomatosis
Duodenopancretactomie cephalic part. (Iconography
of surgery visceral I)
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Treatment
Other methods
The endoscopic ampullectomy Tm small
ampullary benign or malignant is not invading the
submucosa duodenal Endoscopic sphincterotomy
diagnostic, therapeutic preoperative or
palliative therapy Biliary drainage / -
stent grafts Tm locally advanced
Radio-chemotherapy adjuvant TRT after surgical
resection or as palliative
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Evolution and prognosis
The prognosis is better compared to other
peri-ampullary cancers. It is mainly related to
nodal involvement. The prognosis is greatly
improved by early treatment attitude and
thoughtful. The average survival to 5 years is
directly related to tumor stage and nodal
involvement.
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Conclusion
The ampulloma vatérien is a rare tumor, often
malignant. Always think before a cholestatic
jaundice GI bleeding. Ultrasound is the first
review confirm biliary obstruction and
determine the level of obstruction. CT, MRI
with MRI-Sq Bili are fundamental for the
diagnosis and staging. The echo-endoscopy is a
great thing if the cross-sectional imaging is
inconclusive