Two Cases of Hemorrhagic Ampullary Lesions Successfully Treated by Endoscopic Papillectomy

Abstract

We herein report two cases of hemorrhagic ampullary lesions in which endoscopic papillotomy was performed to control bleeding and resulted in successful treatment. Both patients were pathologically diagnosed with an underlying pathology characterized by inflammatory cell infiltration and capillary proliferation. They also had disposing factors for bleeding, such as antithrombotic therapy and idiopathic thrombocytopenic purpura. Endoscopic treatment was selected because the risk of surgical resection was high due to the patients' hemorrhagic condition. Both patients were successfully treated without any serious adverse events and had an uneventful postoperative course with no relapse of bleeding.

Keywords: ampulla of Vater; ampullary lesion; bleeding; endoscopic papillectomy; hemorrhagic.

Figure 1.

A highly erythematous raised lesion with white coating was found in the duodenal papilla. When washed, the lesion bled easily.

Figure 2.

Endoscopic papillectomy (EP). A: The papilla was 8 mm in size. B: The lesion was resected by energizing the snare loop. C: The resected specimen was collected with net forceps. D: The papilla after resection. E: A pancreatic duct stent was placed after EP. F: Appearance of the resection surface one month after EP. The surface is scarred without bleeding.

Figure 3.

Histological view of the resected specimen. A: Low-power view: The lesion was pedunculated and measured 8 mm in size. B: High-power view: Infiltration of inflammatory cells such as neutrophils and macrophages, proliferation of capillaries and fibroblasts, and proliferation of inflammatory granulation tissue consisting of aggregated foreign body-type giant cells were observed.

Figure 4.

An erythematous, swollen, hemorrhagic lesion was found in the duodenal papilla.

Figure 5.

Endoscopic papillectomy (EP). A: The papilla measured 9 mm in size. B: The lesion was resected by energizing the snare loop. C: The resected specimen was collected with net forceps. D: The papilla after resection. E: The anal side of the papilla was plicated with a clip, and bile duct and pancreatic duct stents were placed. F: Appearance of the resection surface one month after EP. The surface is scarred without bleeding.

Figure 6.

Histological view of the resected specimen. A: Low-power view: The lesion was sub-pedunculated and measured 9 mm in size. B: High-power view: Prominent proliferation of small vessels, mainly capillaries, and mild to moderate infiltration of inflammatory cells, mainly lymphocytes and plasma cells, were observed.