St. Luke's University Health Network, Anderson Campus Easton, PA, United States
Aumi Brahmbhatt, MD1, Rodrigo Duarte-Chavez, MD2, Hussam Tayel, MD2, Janak Bahirwani, MD2, Kimberly Chaput, DO3, Ayaz Matin, MD4 1St. Luke's University Health Network, Anderson Campus, Easton, PA; 2St. Luke's University Health Network, Bethlehem, PA; 3St. Luke's University Health Network, Fountain Hill, PA; 4St. Luke's University Hospital, Bethlehem, PA
Introduction: Intraductal papillary neoplasm of the bile duct (IPNB) is a neoplasia variant considered the biliary equivalent of IPMN of the pancreas. Characterized by a papillary growth with or without mucin hypersecretion, it can progress to invasive cholangiocarcinoma and develops along both the intra and extrahepatic bile ducts (BD).
Case Description/Methods: A 79-year-old male with a PMH of anemia, CVA, CHF, CAD, CKD, Afib on anticoagulation was assessed for chronic anemia with CT of the abdomen. A 13mm CBD dilation was found, and this was further assessed with MRI which revealed choledocholithiasis and nodular enhancement of the ampulla. With these findings an ERCP was performed, stones were removed from the CBD and a polypoid mass was seen distally in the CBD and a plastic stent was placed, biopsy from the mass showed IPNB with low grade dysplasia. Another ERCP (Fig 1-B, 1-C) was performed for further assessment, during cholangioscopy the lesion was seen on the distal CBD. Since the patient was deemed a poor surgical candidate, attempts to endoscopically resect the lesion was made. Prior sphincterotomy was extended and the polypoid mass spontaneously extruded into the intestinal lumen (Fig 1-D), then the tumor was resected in a piecemeal fashion with a cold snare, followed by a repeat cholangioscopy, with no apparent tissue remaining (Fig 1-E). A fully covered metal stent was placed in attempts to cause pressure necrosis of any remaining tissue (Fig 1-F). Repeat ERCP with cholangioscopy for surveillance is pending.
Discussion: IPNB is a rare tumor that presents most commonly with abdominal pain, jaundice, and/or cholangitis, or as an asymptomatic intraductal mass with BD dilation. Commonly affecting ages 50-70 with a marginal male predominance, the highest incidence is reported in Eastern countries where risk factors such as hepatolithiasis, choledocholithiasis, and parasitic infections of the BD are common. The WHO classification differentiates IPNB as low, intermediate, or high-grade intraepithelial neoplasia and IPNB associated with invasive carcinoma. IPNB mandates treatment irrespective of the presence of malignancy, otherwise the tumor growth can provoke obstructive jaundice which can lead to further morbidity. Surgical resection is considered for tumors without metastasis. Tumors without carcinoma and limited superficial spread can have limited surgical resection aimed to preserve organ function. We describe a case of a distal IPNB with limited superficial spread treated endoscopically.
Figure: A) Polypoid mass and plastic stent in the distal CBD during MRCP B) Polypoid mass in the distal CBD during cholangiogram C) Ampullary region showing previously placed plastic stent D) Distal IPNB better visualized after extended sphincterotomy E) Cholangioscopy after piecemeal resection of IPNB F) Stent placement after resection
Disclosures: Aumi Brahmbhatt indicated no relevant financial relationships. Rodrigo Duarte-Chavez indicated no relevant financial relationships. Hussam Tayel indicated no relevant financial relationships. Janak Bahirwani indicated no relevant financial relationships. Kimberly Chaput indicated no relevant financial relationships. Ayaz Matin indicated no relevant financial relationships.
Aumi Brahmbhatt, MD1, Rodrigo Duarte-Chavez, MD2, Hussam Tayel, MD2, Janak Bahirwani, MD2, Kimberly Chaput, DO3, Ayaz Matin, MD4. P2434 - Endoscopic Resection of Intraductal Papillary Neoplasm of the Bile Duct, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.