Papilla of Vater carcinoma can have various locations, being located at the level of the terminal duct of the bile duct, in the terminal part of the pancreatic duct, in the ampullary cavity or in the epithelium of the duodenal mucosa near the papilla of Vater . . The preoperative diagnosis of malignancy is often not certain and can sometimes only be demonstrated after surgery and subsequent histological evaluation of the operative material.
Clinic
The clinical picture may vary in relation to the site of the neoplasm; in general, the symptoms and signs of biliary obstruction ( progressive jaundice, pruritus ) prevail. Obstruction of the bile ducts can cause distension of the gallbladder, which may become palpable, with the possibility of biliary colic.
In neoplasms originating from the periampullary duodenal mucosa, jaundice may be intermittent, as well as episodes of biliary tract infection, fever, and gastrointestinal bleeding (often small and therefore silent). The particular tendency of these tumors to ulcerate and necrosis often cause the appearance of hemorrhagic phenomena that can lead to iron deficiency anemia .
Abdominal pain of a variable nature, usually unrelated to food, is often present.
Diagnosis
Radiological studies are the only methods capable of detecting the presence of the lesion: therefore, suspicion of an ampulloma is generated by ultrasound, computed tomography or magnetic resonance imaging. Tests such as transhepatic and retrograde percutaneous cholangiography allow cholangiography for the definitive diagnosis, supported by a radiological examination with barium sulfate and an endoscopic study of the second portion of the duodenum for the duodenoampullary form. Brush biopsies of the lower biliary tract can be taken, although accurate diagnosis is not always satisfactory.
The most accurate method is endosonography, which allows direct visualization of the ampulla and the distal bile duct, as well as its sonographic examination.
Treatment
The surgical treatment of ampulloma is the resection of the lesion. Diagnosed at an early stage, the procedure of choice is a duodenocephalopancreatectomy, with subsequent adjuvant (postoperative) chemotherapy. When the disease is too advanced for radical resection or has metastasized (usually to the liver), chemotherapy alone is the option of choice.