Carcinoma of the Ampulla of Vater Clinical Presentation

Updated: May 08, 2018
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
  • Print
Presentation

History

Jaundice is the presenting symptom in 73% of resected patients and in 80% of unresected patients (71% overall) in the 28-year experience published by Talamini et al. [8]

Jaundice may intermittently wax and wane because of central necrosis and sloughing or pressure opening of a minimally obstructed duct. Patients with malignant tumors commonly have jaundice and larger tumors. [9]

Other features are as follows:

  • Progressive weight loss is the second most common symptom in 61%.

  • Abdominal pain and back pain were present in 46%. The abdominal pain usually is dull, aching midepigastric pain or right hypochondriac pain.

  • Back pain may be a sign of advanced stage.

  • Pruritus associated with jaundice in 13-38%.

  • Dyspepsia and vomiting may be present if compromise of the duodenal lumen leads to gastric outlet obstruction.

  • Loss of appetite may be noted.

  • Diarrhea may occur with this tumor due to the absence of lipase within the gut related to pancreatic duct obstruction.

  • Gastrointestinal bleeding occurs in 5% of resected and in 22% of unresected patients.

  • Acute pancreatitis was significantly more common in unresected lesions (28%) compared with resected lesions (2%). [8]

Next:

Physical

Physical examination findings may include the following:

  • The Courvoisier sign, painless jaundice associated with a palpable gallbladder, may be present. Unlike that due to a neoplasm, obstructive jaundice due to a stone causes scarring of the gallbladder, precluding its distension.

  • Fever can occur in the setting of ascending cholangitis.

  • Hepatomegaly can occur.

  • Rarely, patients present with features of acute pancreatitis or migratory thrombophlebitis.

  • Palpable fixed epigastric masses or supraclavicular nodes are signs of advanced disease and inoperability.

Previous
Next:

Causes

The etiology of the disease is poorly understood.

  • Patients with familial adenomatous polyposis (FAP) have an increased risk of both benign and malignant ampullary tumors. [10]

  • As many as 50-90% of patients with FAP develop duodenal adenomas, predominantly concentrated on or around the major papilla. [11]

  • K-ras mutations may be a factor. [12]

  • Microsatellite instability is associated with a better prognosis.

  • Chromosome 17p and 18q loss of heterozygosity are associated with ampullary carcinoma. [13]

Previous