Giant villous duodenal adenoma with malignant change: an unusual cause of obstructive jaundice

Obstructive jaundice can have various causes, and both neoplastic and non-neoplastic lesions have to be considered. In cases of malignant disease, the tumors are usually located in the extrahepatic bile ducts, the pancreatic head, or the ampullaof Vater[1]. In rare cases, the causative lesion originates from the duodenum [2,3]. A 67-year-old man presented with nonspecific right upper quadrantpain and icterus. Laboratory analysis revealed marked cholestasis: alkaline phosphatase 607U/L (normal 35–129U/L), gamma glutamyltransferase1595U/L (normal 0– 66U/L), and total bilirubin 27.2mg/dL (normal 0–1mg/dL). At endoscopy, a huge villous duodenaladenoma was detected, which covered almost the entire duodenalwall (●" Fig.1). Intubation of the ampullaof Vaterwas impossible. A computed tomography (CT) scan showed an irregular, polypoid tumor that was protruding into theduodenal lumen, butwas confined to the bowelwall (●" Fig.2). The pancreaticoduodenectomyspecimen subsequently showed an intraduodenal villous tumor measuring 12.5cm in its largest diameter. The cut surface of the ampullawas firm, yellow–white, and suspicious of malignancy (●" Fig.3). This area measured 1.5cm in its largest diameter. Histology revealed a villous adenoma(with low and high grade dysplasia) with progression to poorly differentiated ampullary adenocarcinoma that was invading both the pancreas and the peripancreatic soft tissue (●" Fig.4). Seven regional lymph node metastases were identified. The patient’s postoperative course was uneventful and he was discharged in good condition 10 days after surgery. Villous adenomasof the duodenum have a predilection for the ampullary region, tend to present with obstructive jaundice, especially if malignancy is present, and Fig.1 Endoscopic view showing a circumferential villous adenomacarpeting almost the entire duodenalwall. Fig.2 Abdominal computed tomography (CT) scan showing an irregular polypoid tumor mass protruding into the duodenallumen (arrows).