Ampullary adenomas: Clinical manifestations and diagnosis
- John A Martin, MD
John A Martin, MD
- Associate Professor, Senior Associate Consultant, and Associate Chair for Endoscopy
- Mayo Clinic
Benign neoplasms of the ampulla of Vater are rare, representing less than 10 percent of periampullary neoplasms [1,2]. Adenomas are the most common benign lesions of the ampulla but have the potential to undergo malignant transformation to ampullary carcinomas [1,3-18]. This topic will review the clinical manifestations and diagnosis of ampullary adenomas. The management of ampullary adenomas and the clinical presentation, diagnosis, and management of ampullary cancer are discussed elsewhere. (See "Treatment of ampullary adenomas" and "Ampullary carcinoma: Epidemiology, clinical manifestations, diagnosis and staging" and "Ampullary carcinoma: Treatment and prognosis".)
Ampullary adenomas are detected in 0.04 to 0.12 percent of individuals in autopsy series [8,19,20]. Ampullary adenomas can occur sporadically, or in the setting of an adenomatous polyposis syndromes, including familial adenomatous polyposis and MUTYH-associated polyposis. Sporadic ampullary adenomas are usually diagnosed in patients older than 40 years of age and most commonly in their seventies. In contrast, patients with ampullary adenomas in the setting of an adenomatous polyposis syndrome are frequently diagnosed decades earlier in the setting of a surveillance program rather than because of symptoms . (See "Clinical manifestations and diagnosis of familial adenomatous polyposis", section on 'Extracolonic manifestations' and "MUTYH-associated polyposis", section on 'Extracolonic manifestations'.)
Clinical features are a consequence of a mass-effect of the adenoma compressing and impeding biliary or pancreatic outflow.
Clinical presentation — Jaundice is the most common presenting symptom and is present in 50 to 75 percent of patients [3,22-25]. It is usually painless or accompanied by a vague or dull ache in the epigastrium . Patients rarely have pruritus and infrequently develop cholangitis . Other symptoms include biliary colic, nausea, and vomiting [3,24,27]. Less commonly, patients can present with acute pancreatitis, iron deficiency anemia, and overt upper gastrointestinal bleeding [22,27-31].
Imaging features — Patients with ampullary adenomas usually have evidence of biliary ductal dilation on imaging of the abdomen performed for evaluation of obstructive jaundice. Up to 25 percent of patients have associated common bile duct stones secondary to cholestasis . Abdominal imaging is not diagnostic for an ampullary adenomas as it does not permit direct luminal visualization of the papillary aspect of the ampulla to provide access for tissue acquisition for histopathology. (See 'Diagnosis' below and "Diagnostic approach to the adult with jaundice or asymptomatic hyperbilirubinemia", section on 'Suspected biliary obstruction or intrahepatic cholestasis'.)
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