**3.6 Changes of mucosal folds**

Although the tumor process originates from the epithelium of the structures of the ampulla of Vater, its location makes the effect on the duodenal mucosal folds important.

In 70% of vaterian ampullomas, modifications of the mucosal folds are described, and unlike the primitive duodenal malignancies, there are also 30% of cases in which there is no evidence of duodenal mucosal damage.

Alignment of the extremities of the folds on the internal contour of the descending duodenum may indicate a neoplastic process, either ampullary or neighboring—head of the pancreas–but may also be encountered in the case of pancreatitis or perivisceritis, being a nonspecific sign. In the case of the vaterian ampullomas, the alignment of the folds takes place above the papilla (**Figure 7**).

The presence of disorganized folds, although reduced in number, is important from a diagnostic point of view [1], being considered the disorganized folds in the descending duodenum as a sign of damage to the duodenal papilla. It can be concluded that this type of radiological modification cannot differentiate between ampullary malignancies and invasion of the ampulla of Vater by pancreatic cephalic neoplasms.

A more important extension at the level of the duodenal mucosa determines the presence of folds interrupted at the level of the second topographic segment of the duodenum.

**93**

**Figure 8.**

*Duodenal parietal change in the papilla.*

*Radioimaging Diagnosis of Vaterian Ampulloma: Technique, Semiology, and Differential…*

endoscopically, possibly with the association of multiple biopsies.

plastic invasion or an inflammatory reaction (**Figure 8**).

The existence of ampulla of Vater adenocarcinoma does not, however, require the disappearance of all mucosal folds at the papilla level. A neoplastic infiltration of the papilla can lead to the deletion of the longitudinal fold and at the same time to a thickening of the superior fold, in which the diagnosis can only be made

It should be noted that the dual contrast method of duodenography allows for a much more reliable study of mucosal folds, especially those at the duodenal papilla level, which requires maximum distension of the duodenal lumen, as well as

Direct measurement of the thickness of the duodenal wall, either by computed tomography or magnetic resonance examination, is one of the most reliable indicators that show the damage of the duodenal wall, regardless of whether it is a neo-

If one compares the changes in the thickness of the duodenal wall from the duodenal tumors and the vaterian ampullomas, it is concluded that the ratio is exactly reversed, that is, in the case of the ampullomas, the probability that the duodenal wall has a normal thickness is 80%. Thus, the thickened wall raises the assumption of a primitive duodenal neoplasm more quickly than of a vaterian ampulloma but

At the same time, the analysis of the dimensions of the parietal thickening according to the classification in the three subgroups, namely, the wall thickness with values between 4–6, 6–8, and over 8 mm, will show that in the case of the

In conclusion, in the case of an ampullary neoplasia besides the fact that the probability of the presence of a thick duodenal wall is relatively small, in less than one fifth of cases, this thickening is minimal, the duodenal wall not exceeding 6 mm, as opposed to the duodenal malignancies in which at least in two-thirds of

Also, the parietal thickening, in the case of neoplasms of the ampulla of Vater, has been shown to be unilateral, so it is an impairment of the duodenal wall through

The measurement of the parietal thickness is done either within the CT scan or

As with parietal thickening, the study of tumoral extension, either by contiguity, or by lymphatic or blood route, of the vaterian ampullomas is carried out by the

vaterian ampullomas, the wall can be thickened only up to 6 mm.

the cases we encountered a parietal thickening of more than 6 mm.

by magnetic resonance scan, the results being identical [1, 21, 22].

*DOI: http://dx.doi.org/10.5772/intechopen.89948*

double-contrast air-barium exploration.

contiguity and at the same time limited.

**3.7 Thickness of the duodenal wall**

does not exclude it.

**3.8 Tumor extension**

**Figure 7.** *Folds aligned above the lesion.*

### *Radioimaging Diagnosis of Vaterian Ampulloma: Technique, Semiology, and Differential… DOI: http://dx.doi.org/10.5772/intechopen.89948*

The existence of ampulla of Vater adenocarcinoma does not, however, require the disappearance of all mucosal folds at the papilla level. A neoplastic infiltration of the papilla can lead to the deletion of the longitudinal fold and at the same time to a thickening of the superior fold, in which the diagnosis can only be made endoscopically, possibly with the association of multiple biopsies.

It should be noted that the dual contrast method of duodenography allows for a much more reliable study of mucosal folds, especially those at the duodenal papilla level, which requires maximum distension of the duodenal lumen, as well as double-contrast air-barium exploration.
