Ampullary Neoplasia

The ampulla of Vater is the most common site of duodenal neoplasia. The most common neoplastic lesion is adenomatous change, although a large number of other pathologies have been reported at this site. The ampulla is a very common site of adenomatous change in familial adenomatous polyposis (FAP) patients, though many sporadic adenomas also occur in this area. Adenomas of the ampulla may undergo malignant change in a manner similar to colorectal adenomas. Periodic inspection of the ampulla and proximal duodenum is part of standard surveillance for patients with FAP syndrome. In the symptomatic patient, presentation is typically a sequelae of obstruction of the biliary and/or pancreatic duct. However, many lesions are detected in asymptomatic patients undergoing gastroscopy or in FAP patients undergoing routine surveillance. Fortunately, many patients present relatively early, often before malignant transformation has occurred. These patients can be managed very successfully with endoscopic resection. Therefore clinical workup is aimed at determining whether overt malignancy is present and whether the lesion is localized to the duodenal wall and thus amenable to endoscopic therapy. Endoscopic ultrasound and ERCP are both useful in this regard. Patients with malignant lesions usually require pancreaticoduodenectomy.