RECURRENT ACUTE PANCREATITIS WITH A BULGING PAPILLA – AN UNEXPECTED DIAGNOSIS

Adenomas of the biliary tree are a rare entities, being located in most cases in the gallbladder. However, they can be located in any segment of the biliary tree. The natural history of these lesions is not well established, but is postulated to be similar to the adenoma-adenocarcinoma sequence existing elsewhere in the gastrointestinal tract; consequently, removal of the adenomatous lesion may prevent the development of adenocarcinoma.

We present an 87-year-old man with a history of two episodes of acute pancreatitis without identified etiology, referenced for an echoendoscopy. The echoendoscopic study showed a 15 mm x 10 mm isoechoic image in the terminal bile duct, with a heterogeneous aspect, with no associated shadow cone. An ERCP was performed. In the ERCP the endoscopic view of the ampulla, showed an enlarged and bulging ampulla, with normal mucosa. The cholangiogram has shown an image of subtraction in the 1/3 distal of the main bile duct, approximately 20 mm in diameter, compatible with a calculi.

After the biliary sphincterotomy, a biliary sweepage was performed using a Dormia basket revealing a villous polypoid lesion of about 20 mm emanating from the bile duct into the duodenum. Biopsies were performed which confirmed to be a villous adenoma with low grade dysplasia. Given the age and co-morbidities of the patient, surgery was precluded and ablation was performed with argon plasma and the patient will now undergo cholangioscopy for evaluation.

We highlight this case not only because of the rarity of this pathology, but also because of the diagnostic challenge it posed.