CT Evaluation of the Bulging Papilla with Endoscopic Correlation

Abstract

A variety of pathologic conditions can cause abnormalities of the ampulla of Vater. A bulging papilla is frequently encountered at computed tomography (CT) and can be seen in healthy individuals as well as in patients with various pathologic conditions such as papillitis, ampullary cancer, and intraductal papillary mucinous tumor. Mural thickening and certain attenuation patterns seen at contrast material-enhanced CT can help differentiate pathologic papilla from normal papilla. Increased targetlike enhancement of the papilla is likely to represent a benign condition such as papillitis, whereas an enhancing polypoid mass or focal asymmetric or irregular thickening with prolonged enhancement in the ampulla of Vater indicates a malignant condition such as ampullary or periampullary carcinoma. Although CT often does not clarify the exact cause of bulging, adequate duodenal distention may allow detection of an abnormal papilla, thereby providing additional information about other abnormalities in the pancreaticobiliary system. Thus, CT findings may prove useful for subsequent imaging studies such as magnetic resonance (MR) cholangiography or endoscopy. MR cholangiography may be equivalent to CT for identifying a bulging papilla and superior for distinguishing the underlying cause. However, endoscopy with or without biopsy is the best method for making a definitive diagnosis in patients with a bulging papilla. Familiarity with the normal imaging anatomy of the periampullary region and with the imaging features of the various pathologic causes of a bulging papilla may be useful in making the diagnosis.

Frequency in Curative Surgical Treatment of Periampullary Tumors. Experience Based on 122 Cases

“…Esto permite identiicar al grupo de pacientes que puede beneiciarse con una cirugía (pancreatoduodenectomía), o bien, en otros casos, evitar una intervención quirúr-gica innecesaria. Por ejemplo, en un tumor ampular coninado al esfínter de Oddi la cirugía mínimamente invasiva es la elección (papilectomía transduodenal); en caso de un cáncer duodenal la resección duodenal local puede ser suiciente (18,19) . Si se determina la irresecabilidad tumoral en el preoperatorio, se debe realizar una paliación miniinvasiva (no quirúrgica) de la ictericia, ya sea mediante un drenaje endoscó-pico o bien por vía percutánea (utilizando preferentemente drenajes internos mediante el empleo de stents).…”

Differentiation of noncalculous periampullary obstruction: comparison of CT with negative-contrast CT cholangiopancreatography versus MRI with MR cholangiopancreatography

“…In accordance with that study, 24.1 % to 31.0 % of patients with benign periampullary obstructions were observed to have a mass in this study. As opposed to PHC, AC typically manifests as small tumour at the time of diagnosis because of the relatively early onset of symptoms at imaging [24] and its enhancement pattern varies from hypervascular [5,8] to hypovascular appearances according to tumour size or type [1,15]. In this study, four benign obstructions on the CT set and three on the MRI set were misdiagnosed as AC by reviewer 1 compared with six and four, respectively, misdiagnosed as AC on the CT set and MRI set by reviewer 2.…”

“…First, because patients with noncalculous periampullary obstructions were included, a selection bias is possible, as some impacted stones at the distal bile duct may mimic a tumour [8,15]. Second, 12 in 29 patients with benign obstructions were not diagnosed surgically or pathologically, i.e., the final diagnosis was mainly based on imaging follow-up.…”

“…with 7 years of experience in abdominal CT and MRI, who was not involved in the image analysis) performed the CT and MR image post-processing on each of the workstations. The radiologist first created CT multiplanar reconstruction (MPR), including curved planar reconstruction (CPR) images with the portal venous phase source images, and then nCTCP yielded with both a thinslab (thickness of 5-20 mm) MinIP and subvolume MinIP technique, which is reconstructed from volumes smaller than the entire liver data set by using vari-slice manual cut and erosion functions in 3D tools according to the reported literature [13,15]. For the subvolume MinIP, the total segmented width for the nCTCP ranged from 60 to 90 mm (mean 80 mm), which integrated the extrahepatic bile and pancreatic ducts, and the duodenum.…”

“…Benign periampullary obstruction was considered present on CT and MRI if there was: (1) a dilated bile duct showing gradually tapering from the proximal extrahepatic bile duct down to the obstructive site with smooth and symmetric ductal wall [4,9], (2) a short-segment involvement with smooth concentric narrowing of the bile duct lumen as well as a central biliary dilatation without a discernible mass [14], or (3) a perceivable mass < 13 mm [4] with relatively hyperdense/intense or isodense/intense enhancement during the portal venous phase CT and MRI to the normal pancreatic parenchyma or duodenal mucosa [15]. Malignant periampullary obstruction was considered on CT and MRI if there was: (1) direct visualization of a hypodense or hypointense mass relative to the normal pancreatic or hepatic parenchyma at the obstructive level [8,16,17], (2) an irregular thickened ductal wall that obliterated the lumen and demonstrated contrast enhancement [14,18], or (3) a thickened duodenal wall with relatively narrowed duodenal lumen or irregular overhanging edges in the periampullary regions with an abrupt and asymmetric obstruction of bile duct with proportional dilated duct [17].…”