Endoscopic Management

The clinical decision for endoscopic management of an ampullary lesion depends on accurate histologic differentiation between adenoma and carcinoma. A negative mucosal biopsy does not completely rule out the presence of carcinoma, as carcinoma may still be present in adjacent tissue or deeper layers. Ulceration of the lesion is the only endoscopic finding that predicts adenocarcinoma. Biopsy of an ulcerated lesion should be obtained from the margin of the ulcer, rather than the necrotic base of the ulcer. Ampullary neoplasms can extend into the bile duct or pancreatic duct. The presence of malignancy may be missed in up to 30% of cases if mucosal biopsies were obtained alone. Endoscopic sphincterotomy can increase the diagnostic yield of endoscopic mucosal biopsy, by facilitating intra-ductal or submucosal sampling. ERCP should be performed to identify intraductal extension, as this usually warrants surgical resection. EUS may be helpful in further assessing deep layer disruption suggesting malignancy. Papillary adenomas, like adenomatous polyps elsewhere in the gastrointestinal tract are premalignant. Therefore, the therapeutic goal should be complete endoscopic removal of adenomatous tissue using a combination of snare excision and thermal ablation. Saline injection with methylene blue may facilitate removal of small or sessile portions. Small lesions may be removed en bloc, whereas larger lesions may be removed piecemeal. Current data suggests that the placement of a 3 cm, 5 F pancreatic stent can reduce the risk of postprocedure pancreatitis (Figure 1344). Residual tumor may be ablated with argon plasma coagulation (ERBE APC, ERBE USA Inc, Marietta, GA), or YAG laser. Complications of snare ampullectomy include those of ERCP, including pancreatitis, local bleeding, and rarely perforation. In a series of 26 patients undergoing endoscopic snare excision of duodenal ampullary adenomas, the incidence of pancreatitis (14%), bleeding (7%), and perforation (3.5%) was significantly higher than the complication rates seen in ERCP.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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