Ampullectomy of a bulky pedunculated ampullary lesion. A 67-year-old patient with hematemesis and melena. For one day, patient had history of diabetes for 15 years. On admission, patient had paler tachycardia and hypotension. Her hemoglobin was 3.4 on admission. Patient was resuscitated and received 4 PCV. Ultrasound abdomen was normal. An upper GA endoscopy was done, which revealed a bulky and pedunculated ampulla with an ulcer over it. Sideway endoscopy showed a bulky and pedunculated ampulla with an ulcer with an active ooze. PUS revealed a submucosal lesion which was hypoechoic and was hypervascular on color Doppler. CECP abdomen revealed a polypoidal intraluminal lesion arising from the posterior medial wall of D2 and having luminal projection. The lesion was abutting medial surface of the pancreatic hand without infiltration. Lesion was intense enhancement on arterial and arterio-portal phase and mild persistent enhancement without washout on venous phase. A pancreatic duct stent was placed and endotrope was applied first. The pathology showed gangliocytic paraganglioma involving mucosa and submucosa with focal surface ulceration. Post procedure course was uneventful and patient was discharged after 48 hours. At 2 months follow up, patient was asymptomatic. Relook endoscopy showed no lesion. Previously placed pancreatic duct stent had migrated spontaneously.

hematemesis

ampullary lesion

PCV transfusions

pancreatic duct stent

submucosal lesion