This 71 year old man was feeling weak and dizzy and had noted some black bowel movements over the past few weeks. He saw his doctor for a checkup and was found to be anemic. A test of a stool specimen showed some blood. Since he had had a colonoscopy in the recent past, his doctor felt that the bleeding was not coming from the lower digestive system, or large intestine. This made it more likely that he was bleeding from the upper digestive system instead, most likely from an ulcer. A gastroscopy "scope" test was performed. There was no ulcer. The photos above show the source of bleeding. There is a cancer forming on the Ampulla of Vater, which is the small nipple in the wall of the duodenum, or upper small intestine. This is where the pancreas and liver drain their secretions into the intestinal tract to help digest the food. Cancer of the Ampulla is very rare, but is the most common primary cancer to arise from the small intestinal wall. The usual presentation is jaundice from blockage of the bile duct, but some cases present, as above, with bleeding. If the cancer has not spread, treatment is a major abdominal operation to remove the Ampulla, and part of the pancreas and bile duct, called a Whipple prodedure. The biopsy of this patient showed "infiltrating, poorly-differentiated adenocarcinoma." Adenocarcinomas are tumors that are derived from glandular structures. Such glandular structures are present within the inner linings, or mucosa, of the respiratory tract, gastrointestinal tract, genital tract, urinary tract and endocrine organs. They are classified according to the extent of gland formation as: well differentiated adenocarcinomas moderately differentiated adenocarcinomas poorly differentiated adenocarcinomas The well differentiated adenocarcinomas largely consist of glands and have the best prognosis for treatment, whereas in the poorly differentiated tumors, glands are rarely formed. Poorly differentiated cancer such as this do not respond well to treatment and have the worst prognosis. Unfortunately, the second photo shows that this patient's cancer has already begun to spread within the intestinal wall, making treatment very difficult. The prognosis for this man is not good.

Text & Images Courtesy of Three Rivers Endoscopy Center
© Dr. Robert Fusco, Three Rivers Endoscopy Center, All Rights Reserved