Introduction
A 35-year-old lady with a history of symptomatic iron deficiency anemia and positive
fecal occult blood. Prior evaluation showed normal upper gastrointestinal (GI) endoscopy
and ileocolonoscopy. Small bowel evaluation with computed tomography enterography
and capsule endoscopy were normal. Patient was again evaluated at our center. Upper
GI endoscopy showed erythematous lesion at the ampullary region. Side view endoscopy
showed erythematous, polypoidal lesion at the ampulla with intermittent oozing of
blood ([Fig. 1A]). With suspicion of ampullary malignancy, Endoscopic ultrasound was done, which
showed hyperechoic, small lesion measuring less than 1 cm at the ampulla and not involving
the deeper layers of the duodenum, bile duct, and pancreatic duct ([Fig. 1E]). Due to its superficial location, patient was taken for ampullectomy ([Fig. 1B]). Biopsy was not done prior to ampullectomy in view of small superficial lesion.
Initially, gelofusine was instilled around the ampulla and using snare, hot snare
ampullectomy was done. Specimen was retrieved with Roth Net. Ampullectomy base was
clean with no bleeding. Prophylactic pancreatic duct stent (SPT 5Fr × 3cm) was placed
to prevent pancreatitis ([Fig. 1C]). Histopathology of ampullectomy specimen showed congested and dilated capillaries
with few inflammatory cells suggestive of pyogenic granuloma ([Fig. 1D]). Patient was monitored as inpatient for 3 days prior to discharge. After 2 weeks,
patient remained asymptomatic with stable hemoglobin. Pancreatic duct stent was removed.
Patient completed 4 months of follow-up with stable hemoglobin without any blood or
intravenous iron transfusion.
Fig. 1 (A) Side view endoscopic view of the ampulla showing erythematous polypoidal lesion
with fragile mucosa. (B) Resection of the ampulla with hot snare polypectomy. (C) Post-ampullectomy status and prophylactic pancreatic duct placement. (D) Histology of resected specimen: hematoxylin and eosin (H&E) staining, magnification
view ×400 showing proliferation of capillaries lined with endothelial cells (marked
as *) admixed with acute and chronic inflammatory cells (marked as #). (E) Endoscopic ultrasound image showing common bile duct (yellow arrow), pancreatic
duct (white arrow), and small hypoechoic lesion in the periampullary region (orange
arrow).
Pyogenic granuloma is a benign vascular proliferation usually seen in children and
young adults on skin and mucous membranes. It rarely involves the GI tract and ampullary
involvement is uncommon. Ampullary site of pyogenic granuloma is very rare and reported
in only few case reports.[1]
[2]
[3]
