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Nojima H, Shimizu H, Hirota M, Murakami T, Yamazaki M, Yamazaki K, Shuto K, Kosugi C, Mori M, Usui A, Sazuka T, Koda K. An ampullary adenoma presenting with jaundice caused by duodenal intussusception: a case report. Surg Case Rep 2024; 10:25. [PMID: 38252200 PMCID: PMC10803710 DOI: 10.1186/s40792-024-01822-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Ampullary adenomas are premalignant lesions. However, biliary obstruction causing jaundice is rare. Duodenal intussusception secondary to an ampullary adenoma rarely occurs because of the fixed position of the duodenum in the retroperitoneum. Herein, we have described a rare case of ampullary adenoma with jaundice caused by duodenal intussusception. CASE PRESENTATION A 40-year-old woman presenting with vomiting and yellowish discoloration of the skin was admitted to another hospital. The patient had experienced recurrent epigastric pain and vomiting for the past 18 months. Blood test results showed elevated levels of bilirubin (3.9 mg/dL), and abdominal computed tomography (CT) showed a 60-mm hypovascular mass in the third part of the duodenum and a left lateral shift of the dilated common bile duct. The patient was referred to our hospital for further evaluation. She recovered from hyperbilirubinemia spontaneously (levels of bilirubin, 1.0 mg/dL), and the CT showed a tumor shift from the third part of the duodenum to the second part and improvement of the dilated common bile duct. Hypotonic duodenography revealed a tumor that moved easily from the second to the third portion of the patient's position. Upper gastrointestinal endoscopy revealed a large papillary tumor occupying the second part of the duodenum, which was diagnosed as an adenoma through biopsy. The possibility of malignancy could not be negated owing to the presence of jaundice and an elevated carbohydrate antigen 19-9 level (76.0 U/mL). Pancreaticoduodenectomy was performed. The resected specimen showed a 60 × 40 × 40-mm pedunculated ampullary mass with submucosal elongation. The pathological examination indicated that the ampullary tumor was a high-grade intestinal adenoma. The postoperative course was uneventful, and the patient was discharged 26 days postoperatively. CONCLUSIONS This report describes a rare case of a patient with an ampullary adenoma presenting with jaundice resulting from duodenal intussusception. Owing to the possibility of a postoperative cancer diagnosis which may have caused the biliary obstruction and the difficulty in making an accurate preoperative diagnosis, it is imperative to choose the appropriate surgical procedure such as a pancreaticoduodenectomy.
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Affiliation(s)
- Hiroyuki Nojima
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Hiroaki Shimizu
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan.
| | - Mihono Hirota
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Takashi Murakami
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Masato Yamazaki
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Kazuto Yamazaki
- Department of Pathology, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Kiyohiko Shuto
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Chihiro Kosugi
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Mikihito Mori
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Akihiro Usui
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Tetsutaro Sazuka
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
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Hirata M, Shirakata Y, Yamanaka K. Duodenal intussusception secondary to ampullary adenoma: A case report. World J Clin Cases 2019; 7:1857-1864. [PMID: 31417932 PMCID: PMC6692261 DOI: 10.12998/wjcc.v7.i14.1857] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/13/2019] [Accepted: 05/23/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Because the duodenum is fixed onto the retroperitoneum, duodenal intussusception is usually impossible except in cases of malrotational abnormality. Although cases of duodenal intussusception without malrotational abnormalities have been reported, it is unclear whether they constitute true intussusception or simple mucosal prolapse.
CASE SUMMARY A 66-year-old woman presented with whole-body edema and malaise. Blood analysis indicated severe anemia and cholestasis. Endoscopic examination revealed a pedunculate polyp on the second part of the duodenum that migrated distally with mucosal elongation. Computed tomography showed duodenal intussusception. A tumor as the lead point and retroperitoneal structure, including the head of the pancreas and fat, invaginated beyond the duodenojejunal flexure. She was diagnosed with ampullary adenoma caused repeated intussusception that reduced spontaneously and underwent pancreaticoduodenectomy. Laparotomy showed tumor prolapse beyond the duodenojejunal flexure without intussusception. There was no evidence of malrotational abnormality. She was discharged with no complications.
CONCLUSION We report true duodenal intussusception without malrotational abnormality. This phenomenon was also associated with mucosal prolapse.
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Affiliation(s)
- Masaaki Hirata
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo 660-0892, Japan
| | - Yoshiharu Shirakata
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo 660-0892, Japan
| | - Kenya Yamanaka
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo 660-0892, Japan
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Abstract
Enteroenteric intussusception is a condition in which the full-thickness bowel wall becomes telescoped into the lumen of distal bowel. Intussusception in adult occurs infrequently and varies from childhood intussusception, particularly in its presentation, aetiology and treatment. Duodenoduodenal intussusception is rare because the duodenum is fixed in the retroperitoneal position. It usually occurs secondary to tumour, lipoma, Brunner's gland hamartomatous polyp or adenoma. The diagnosis in adults is usually made at laparotomy, where presentation is with intestinal obstruction. In non-emergency presentation, it may be difficult to arrive at an accurate diagnosis as symptoms may be vague, self-limiting intermittent abdominal pain. Clinical examinations and investigations may not be conclusive and another working diagnosis such as irritable bowel syndrome would be made. We describe a case where a patient initially presented with symptoms mimicking pancreatitis but his symptoms persisted over the course of 2 weeks. When a laparotomy was performed, duodenoduodenal intussusception was discovered and confirmed with histopathology. In this case, a discernible leading point could not be identified.
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Affiliation(s)
- G H Loo
- General Surgery, Bintulu Hospital, Bintulu City , Bintulu , Malaysia
| | | | - S L Lim
- General Surgery, Bintulu Hospital, Bintulu City , Bintulu , Malaysia
| | - A M Ismail
- Pathology Department, Hospital Umum Sarawak , Kuching, Sarawak , Malaysia
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De Silva WSL, Pathirana AA, Gamage BD, Manawasighe DS, Jayasundara B, Kiriwandeniya U. Extra-ampullary Peutz-Jeghers polyp causing duodenal intussusception leading to biliary obstruction: a case report. J Med Case Rep 2016; 10:196. [PMID: 27423470 PMCID: PMC4947321 DOI: 10.1186/s13256-016-0990-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 06/24/2016] [Indexed: 12/20/2022] Open
Abstract
Background Duodenal Peutz–Jeghers polyp is a rare cause of duodenal or biliary obstruction. However, a sporadic Peutz–Jeghers polyp leading to simultaneous biliary and duodenal obstruction has not been reported. Case presentation We report a case of a 25-year-old Sri Lankan woman presenting with features of recurrent upper small intestinal obstruction and biliary obstruction. She had clinical as well as biochemical evidence of intermittent biliary obstruction. Evidence of duodenal intussusception was found in a computed tomography enterogram and a duodenal polyp was noted as the lead point. Marked elongation and distortion of her lower common bile duct with intrahepatic duct dilatation was also noted and the ampulla was found to be on the left side of the midline pulled toward the intussusceptum. Open polypectomy and reduction of intussusception were done and she became fully asymptomatic following surgery. Histology of the resected specimen was reported as a typical “Peutz–Jeghers polyp”. As there was not enough evidence to diagnose Peutz–Jeghers syndrome this was considered to be a sporadic Peutz–Jeghers polyp. Conclusion Rare benign causes such as a duodenal polyp should be considered and looked for in initial imaging, when the cause for concurrent biliary and intestinal obstruction is uncertain, particularly in young individuals.
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Affiliation(s)
- W S L De Silva
- Post-Graduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka.
| | - A A Pathirana
- Department of Surgery, Faculty of Medical Sciences, University of Sri Jayewardenepura, Colombo, Sri Lanka
| | - B D Gamage
- Department of Surgery, Faculty of Medical Sciences, University of Sri Jayewardenepura, Colombo, Sri Lanka
| | - D S Manawasighe
- Post-Graduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | - B Jayasundara
- Post-Graduate Institute of Medicine, University of Colombo, Colombo, Sri Lanka
| | - U Kiriwandeniya
- Department of Pathology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Colombo, Sri Lanka
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Patankar AM, Wadhwa AM, Bajaj A, Ingule A, Wagle P. Brunneroma: A Rare Cause of Duodeno- duodenal Intussusception. Euroasian J Hepatogastroenterol 2016; 6:84-88. [PMID: 29201733 PMCID: PMC5578567 DOI: 10.5005/jp-journals-10018-1174] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/20/2015] [Indexed: 01/25/2023] Open
Abstract
Brunner gland hamartoma (brunneroma) is a rare benign tumor of the duodenum. It is usually asymptomatic and detected incidentally by endoscopy or other imaging modality. The definitive diagnosis is based on histopathological findings. These may mimic tumors of other natures, such as gastrointestinal stromal tumors (GIST), carcinoids, lipomas, and leiomyomas. Here, we present a case of duodenal polyp presenting with abdominal pain and obstructive symptoms that caused duodenal intussusception. It was surgically removed and found to be a brunneroma on histopathology.
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Affiliation(s)
- Aparna M Patankar
- Department of Radiology , Lilavati Hospital and Research Centre, Mumbai, Maharashtra , India
| | - Anju M Wadhwa
- Department of Radiology , Lilavati Hospital and Research Centre, Mumbai, Maharashtra , India
| | - Aneeta Bajaj
- Department of Radiology , Lilavati Hospital and Research Centre, Mumbai, Maharashtra , India
| | - Amol Ingule
- Department of Radiology , Lilavati Hospital and Research Centre, Mumbai, Maharashtra , India
| | - Prasad Wagle
- Department of Gastrointestinal Surgery, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
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