case_images: PMC7218460_01
case_images: (A). Abdominal contrast-enhanced CT revealed a circumferential stenosis of the duodenum (arrows). (B). An extremely mild thickening of the lower bile duct wall (arrow).
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case_images: Abdominal contrast-enhanced CT revealed a circumferential stenosis of the duodenum and an extremely mild thickening of the lower bile duct wall (Figure 1A and B).
case_images: (A & B). EGD showed that the papilla of Vater was mildly enlarged and that the anal side of the papilla of Vater in the descending portion of the duodenum showed a circumferential edematous stenosis. (C). Contrast agent did not flow toward the anal side; therefore, he was diagnosed with type III duodenal stenosis (arrows). (D). EUS revealed a thickening of the duodenal mucosal layer (arrow). (E). EUS showed no stenosis/wall thickness of the common bile duct (arrow). (F). EUS-FNA of the enlarged papilla of Vater was performed.. EGD indicates esophagogastroduodenoscopy; EUS, endoscopic ultrasonography; EUS-FNA, EUS-guided fine-needle aspiration.
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case_images: EGD showed that the papilla of Vater was mildly enlarged and that the anal side of the papilla of Vater in the descending portion of the duodenum showed a circumferential edematous stenosis (Figure 2A and B). The EGD scope (GIF-HQ290, Olympus Co, 10.2 mm in diameter of the distal end) could pass through the stenotic site, but the contrast agent did not flow toward the anal side; therefore, he was diagnosed with type III duodenal stenosis (Figure 2C). Endoscopic ultrasonography (EUS) revealed a thickening of the duodenal mucosal layer (Figure 2D), and no stenosis/wall thickness of the common bile duct (Figure 2E). EUS-guided fine-needle aspiration (EUS-FNA) of the papilla of Vater and enlarged lymph nodes were performed (Figure 2F), but the findings showed no malignancy.
case_images: (A). Abdominal CT was performed 1 month after discharge from our department, the findings showed an exacerbation of the thickening of the distal bile duct wall (arrow). (B). EUS revealed a smooth wall thickening from the papilla of Vater to the lower bile duct (arrow). (C). ERCP image showed a smooth stenosis in the lower bile duct (arrows). (D). There was no dilation of the main pancreatic duct, 1.6 mm in diameter, on EUS (arrow). (E). There was no dilation of the main pancreatic duct on MRCP.. EUS indicates endoscopic ultrasonography; ERCP, endoscopic retrograde cholangiopancreatography; MRCP, magnetic resonance cholangiopancreatography.
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case_images: However, the findings showed an exacerbation of the thickening of the distal bile duct wall (Figure 3A). EUS revealed a smooth wall thickening of the lower bile duct (Figure 3B); however, it was difficult to detect the lower bile duct which was located near by the ampulla due to stenosis of duodenal second portion. The endoscopic retrograde cholangiopancreatography (ERCP) image showed a smooth stenosis in the lower bile duct (Figure 3C). In addition, there were no abnormal findings (mass, dilated pancreatic duct) of the pancreas on EUS/MRCP (Figure 3D and E).
case_images: (A & B). A biopsy of the stenosed bile duct under ERCP revealed a well-differentiated adenocarcinoma (HE, 100x, 200x). (C & D). Immunostaining of CK7 and CK20 for the stenosed bile duct. Positive for CK7 and negative for CK20 were identified (100x). (E & F). A peritoneal nodule was subjected to an intraoperative rapid pathological diagnosis, and the findings revealed a poorly differentiated adenocarcinoma partially mixed with a signet-ring cell, carcinoma-like component (HE, 100x, 200x). (G & H). Immunostaining of CK7 and CK20 for a peritoneal nodule. Positive for CK7 and negative for CK20 were identified (x100).
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case_images: A biopsy of the stenosed bile duct under ERCP revealed a well-differentiated adenocarcinoma (Figure 4A and B). A peritoneal nodule was subjected to an intraoperative rapid pathological diagnosis, and the findings revealed a poorly differentiated adenocarcinoma partially mixed with a signet-ring cell, carcinoma-like component (Figure 4C and D). Immunohistochemistry showed positive cytokeratin 7 (CK7), and negative cytokeratin 20 (CK20) (Figure 4E to H).