Duodenal adenocarcinoma is very rare among the general population. The diagnosis may be delayed until advanced stages, due to the subtle and nonspecific clinical manifestations of that rare pathology. Abdominal pain, upper gastrointestinal bleeding, weight loss and biliary obstruction may be the main patient’s complaints. We present a very interesting case of an old patient with dementia, hospitalized with a clinical, laboratory and imaging state consistent with cholangitis. Conservative therapy with antibiotics and an urgent ERCP was held, during the procedure, the major papilla could not be identified due to distorted anatomy of the second and third parts of the duodenum. Torsion like appearance of the duodenum was observed. Consequentially, the patient biliary tract was drained by inserting an internal– external drain percutaneously. Following the external drainage, a successful gastroscopy was done, with successful exploration of the proximal duodenum, revealing the true cause of the bile duct obstruction; a large pedunculated polypoid mass (approx. 30 mm), in proximate to the major papilla was found as well as the distal pigtailed plastic stent with was inserted as mentioned during angiography. The mass diagnosed as duodenal adenocarcinoma in pathology. This unique case describes presentation of an aggressive rare duodenal cancer, mimicking biliary cholangitis distorting the local anatomy. Endoscopic exploration became feasible due to primary percutaneous drainage.
Oren Gal, Dan Feldman, Amir Mari, Fadi Abu Backer and Yael Kopelman
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