P1154 - Bile Duct Surprise from Sepsis: Presentation of Bile Duct Adenoma

Geoffrey Goldsberry, DO¹, Marissa Bournique, DO², Adam Salomon, DO¹, Marc Kudelko, DO^1
1Nova Southeastern University College of Osteopathic Medicine, Largo, FL; ²Nova Southeastern University College of Osteopathic Medicine, Stuart, FL

Introduction: Biliary adenomas are extremely rare lesions leading to difficulty not only in the diagnosis, but also in management and patient care. The diagnosis is often incidental as was the case with our patient who initially presented with abdominal pain and quickly progressed to sepsis related to acute cholangitis. Hospitalization leading to emergent endoscopic retrograde cholangiopancreatography (ERCP) brought us to her diagnosis and subsequent course of management. Controversy lies in the long-term care plan, lack of standardization for treatment, and concerning malignancy potential within these adenomas.

Case Description/Methods: A 71-year-old Caucasian female presented with sudden onset of abdominal pain located within the mid-epigastric region with radiation to her back and bilateral shoulders. Magnetic resonance cholangiopancreatography (MRCP) demonstrated abnormal biliary dilation to the level of the ampulla with a 7mm filling defect within the mid-common bile duct (CBD), concerning for choledocholithiasis.
Shortly after admission, the patient began to develop fevers and rigors for which emergent endoscopic retrograde cholangiopancreatography (ERCP) was arranged due to concern for developing cholangitis. Sphincterotomy/balloon sweep resulted in prolapse of a polypoid appearing irregular lesion into the duodenal lumen. The tissue seemed to originate from within the distal CBD and multiple biopsies were obtained and sent for histology. Pathology results from the polypoid lesion returned as tubulovillous adenoma with low grade dysplasia.

Discussion: It is generally accepted that common bile duct adenomas follow the adenoma to carcinoma sequence seen elsewhere in the GI tract.³ Given this potential, life-threatening malignancy can arise from these initially benign tumors if left untreated. What is paramount to forming an appropriate treatment plan is accurate staging. The approach to treatment and surveillance remains a perplexing task due to the limited number of cases and varying presentations.⁸ Many of these tumors are treated surgically, and not uncommonly with pancreaticoduodenectomy. While radical surgical intervention may be reasonable and appropriate given the malignant potential, these procedures have their own associated morbidity and mortality. Postoperative anastomotic dehiscence and fistula are seen in up to 9% and 14% of patients, respectively, as well as mortality rates from 1% to 9%.⁹




Figure: Endoscopic retrograde cholangiopancreatography (ERCP)


Disclosures:
Geoffrey Goldsberry indicated no relevant financial relationships.
Marissa Bournique indicated no relevant financial relationships.
Adam Salomon indicated no relevant financial relationships.
Marc Kudelko indicated no relevant financial relationships.


Geoffrey Goldsberry, DO¹, Marissa Bournique, DO², Adam Salomon, DO¹, Marc Kudelko, DO¹. P1154 - Bile Duct Surprise from Sepsis: Presentation of Bile Duct Adenoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.