A 68-year-old man is referred for further evaluation and treatment of jaundice. He describes pruritus, intermittent mild midabdominal discomfort, and progressive weight loss. There is no history of fever. His history is significant for renal cell carcinoma with pulmonary metastasis.
The patient’s physical examination is positive for evidence of jaundice, malnutrition, and abdominal distension with hepatomegaly. There is no tenderness. Rectal examination revealed light brown stool that is guaiac-positive.
Workup is significant for abnormal liver chemistries and imaging studies. Bilirubin is 9 mg/100 mL and the alkaline phosphatase is 630 units/L. Abdominal ultrasonography and CT scan reveal filling defects in the liver and marked intra- and extrahepatic bile duct dilatation. In addition, there are multiple enlarged lymph nodes and fullness in the region of the pancreatic head.
Endoscopic retrograde cholangiopancreatography (ERCP) was performed to further evaluate and treat this patient with evidence of biliary obstruction. When the endoscope was passed into the descending duodenum, a large friable mass was noted in the region of the ampulla.
The most likely cause of this patient’s jaundice is:
a. Adenocarcinoma of the ampulla
b. Metastatic ampullary renal cell carcinoma
c. Pseudotumor of the ampulla
d. Biliary stone
The correct answer to the question is b. Although the patient’s history of jaundice and intermittent abdominal pain can be consistent with any of the choices, at endoscopy the patient was found to have malignancy at the ampulla of Vater (hepaticopancreatic ampulla). The histology of the tumor was consistent with the patient’s renal cell carcinoma.