**3.7 Thickness of the duodenal wall**

*Gastrointestinal Stomas*

folds (**Figure 6**).

important.

neoplasms.

duodenum.

pancreas, due to the perilesional edema.

level of the descending duodenum.

**3.6 Changes of mucosal folds**

The imprint may occur due to the segmental enlargement of the head of the

In any case, the imprint due to vaterian ampulloma is less spread on the contour of the descending duodenum than in the case of pancreatic cephalic malignancies. In the case of neoplasms with localization in the head of the pancreas, the association of changes in the extremity of the mucosal folds in the vicinity of the neoplasm is mentioned almost constantly, by the appearance of what bears the name of "T fold." Vaterian ampullomas never associate this change in orientation of the mucosal

The presence of the imprint could possibly be a radiological sign of differentiation between the duodenal malignancies and the vaterian ampullomas but with a higher specificity between the duodenal tumors and any other tumor spread to the

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

Alignment of the extremities of the folds on the internal contour of the descend-

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

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

In 70% of vaterian ampullomas, modifications of the mucosal folds are described, and unlike the primitive duodenal malignancies, there are also 30% of

ing 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,

cases in which there is no evidence of duodenal mucosal damage.

the alignment of the folds takes place above the papilla (**Figure 7**).

**92**

**Figure 7.**

*Folds aligned above the lesion.*

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

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 does not exclude it.

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

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

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 contiguity and at the same time limited.

The measurement of the parietal thickness is done either within the CT scan or by magnetic resonance scan, the results being identical [1, 21, 22].

#### **3.8 Tumor extension**

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

**Figure 8.** *Duodenal parietal change in the papilla.*

two radioimaging methods, namely, computed tomography and magnetic resonance imaging. The comparative results of the two methods proved to be identical.

*The extension by contiguity*, in the case of the ampullary neoplasms, consisted in reality only in the invasion of the pancreatic cephalic portion, the periduodenal space, as we described in the previous subchapters being normal.

Invasion of the head of the pancreas can be detected only in up to 20% of patients with vaterian ampulloma.

If we compare the existing data with those described in the case of the primitive duodenal malignancies, it can be observed that the numbers and the percentages of pancreatic invasions in the case of duodenal neoplasms are higher than the results in the case of the vaterian ampulloma. Thus, duodenal malignancies invade the pancreas in about 30% of cases, while in the case of ampullar carcinoma, this percentage is only 20%. This is an additional argument to support the idea that the vaterian ampulloma is a less aggressive form of neoplasm, even more "benign" than primitive duodenal malignancies.

*The lymphatic extension* results in radio-imagistic findings of adenopathy. In specialized literature, they are described as being possibly present in the case of vaterian ampullomas, as claimed by Semelka et al. [19], but they are extremely rare.

*Extension through the bloodstream* is evidenced by the presence of organ metastases, respectively located in the liver. Semelka et al. [19] describes the possibility of the existence of liver metastases in the case of the vaterian ampulloma.

The frequency of metastasis in ampullary neoplasms has been shown to be lower than in the case of primitive duodenal malignancies.

In conclusion, the vaterian ampullomas are neoplasms with reduced aggression, which is why Talamini et al. [2] state that compared to pancreatic carcinomas, ampullary carcinomas have a significantly higher resectability rate and a much better prognosis.

#### **3.9 Modifications of the biliary and pancreatic ducts**

If, in the case of the duodenal neoplasms, the impairment of the bile ducts was only limited to the increase of the choledoch caliber in a few cases, the dilation in these cases was moderate, that is, it did not exceed 1.5 cm; in the situation of the vaterian ampullae, an enlargement of the bile duct tree size is detected in all cases.

In order to be able to classify the caliber changes of the biliary ducts, we divided the cases into three groups, namely, those with a diameter of less than 1.5 cm, but over 0.9 cm, those with diameters between 1.5 and 2 cm, and those with a caliber of over 2 cm.

The value of 0.9 cm is considered by all authors to be the maximum value of the choledoch duct that can be considered normal.

It can be seen that most of the vaterian ampullomas, that is to say, 70% have a choledoch with a size between 1.5 and 2 cm and over 20% with a size of over 2 cm. A percentage of less than 10% shows a moderate increase in the size of the choledoch duct, i.e., up to 1.5 cm [1] (**Figure 9a, b**).

Semelka et al. [19] concluded that most of the neoplasms of the ampulla of Vater are defined by a significant increase in the size of the choledoch duct, considered by him to be over 1.5 cm, and that only in a limited number of cases does the choledochal dilation not exceed 1.5 cm.

Regarding the radioimaging method for determining the dimensions of the choledoch duct, the same author, in a comparative study, concludes that the magnetic resonance scan, which also includes cholangio-MRI, is superior to the computed tomography, especially due to its ability to detect once again very small processes of

**95**

a noninvasive method.

**Figure 9.**

**Figure 10.**

rarely exceeds 1.5 cm.

invasion by a pancreatic neoplasm.

dimensional evaluation.

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

space replacement at the level of the ampulla of Vater, which are not evidenced by the computed tomographic examination. He also argues that the magnetic resonance method is similar to ERCP from these points of view, but unlike the latter it is

If we compare it with the neoplasms of the head of the pancreas, we will notice that the dilation of the choledoch duct is reduced in terms of caliber, that is, in the case of pancreatic cephalic malignancies, the frequency of the presence of the choledoch dilation is much lower, of only about 30%, and dimensionally the choledoch

Magnetic resonance exploration at the same time allows the study of the con-

The existence of an irregular contour, particular to a neoplastic infiltration, cannot be discussed, considering that the Oddi sphincter usually represents an anatomical barrier in the superior extension of the tumor. The association of the terminal part of the choledoch narrowing with its irregular contours guides the diagnosis either toward a distal cholangiocarcinoma or in the case of a choledochal

This is the reason why the analysis of changes in the biliary duct was limited to

Due to the anatomical position, the ampullar neoplasm also determines the dilation of the duct of Wirsung but only in a third of the cases. Semelka et al. [19] considers the presence of a high-caliber Wirsung as a nonspecific sign, accompany-

ing the choledochal dilation, in a ratio similar to that found in our study.

tours of the terminal part of the choledoch (**Figure 10**).

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

*(a, b) Changes of bile ducts in the vaterian ampulloma.*

*Changes in the bile duct in the ampulloma: Cholangio-MRI.*

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

**Figure 9.** *(a, b) Changes of bile ducts in the vaterian ampulloma.*

#### **Figure 10.**

*Gastrointestinal Stomas*

patients with vaterian ampulloma.

primitive duodenal malignancies.

better prognosis.

over 2 cm.

two radioimaging methods, namely, computed tomography and magnetic resonance imaging. The comparative results of the two methods proved to be identical. *The extension by contiguity*, in the case of the ampullary neoplasms, consisted in reality only in the invasion of the pancreatic cephalic portion, the periduodenal

Invasion of the head of the pancreas can be detected only in up to 20% of

If we compare the existing data with those described in the case of the primitive duodenal malignancies, it can be observed that the numbers and the percentages of pancreatic invasions in the case of duodenal neoplasms are higher than the results in the case of the vaterian ampulloma. Thus, duodenal malignancies invade the pancreas in about 30% of cases, while in the case of ampullar carcinoma, this percentage is only 20%. This is an additional argument to support the idea that the vaterian ampulloma is a less aggressive form of neoplasm, even more "benign" than

*The lymphatic extension* results in radio-imagistic findings of adenopathy. In specialized literature, they are described as being possibly present in the case of vaterian ampullomas, as claimed by Semelka et al. [19], but they are extremely rare. *Extension through the bloodstream* is evidenced by the presence of organ metastases, respectively located in the liver. Semelka et al. [19] describes the possibility of

The frequency of metastasis in ampullary neoplasms has been shown to be lower

In conclusion, the vaterian ampullomas are neoplasms with reduced aggression,

If, in the case of the duodenal neoplasms, the impairment of the bile ducts was only limited to the increase of the choledoch caliber in a few cases, the dilation in these cases was moderate, that is, it did not exceed 1.5 cm; in the situation of the vaterian ampullae, an enlargement of the bile duct tree size is detected in all cases. In order to be able to classify the caliber changes of the biliary ducts, we divided the cases into three groups, namely, those with a diameter of less than 1.5 cm, but over 0.9 cm, those with diameters between 1.5 and 2 cm, and those with a caliber of

The value of 0.9 cm is considered by all authors to be the maximum value of the

Semelka et al. [19] concluded that most of the neoplasms of the ampulla of Vater are defined by a significant increase in the size of the choledoch duct, considered by him to be over 1.5 cm, and that only in a limited number of cases does the chole-

Regarding the radioimaging method for determining the dimensions of the choledoch duct, the same author, in a comparative study, concludes that the magnetic resonance scan, which also includes cholangio-MRI, is superior to the computed tomography, especially due to its ability to detect once again very small processes of

It can be seen that most of the vaterian ampullomas, that is to say, 70% have a choledoch with a size between 1.5 and 2 cm and over 20% with a size of over 2 cm. A percentage of less than 10% shows a moderate increase in the size of the choledoch

which is why Talamini et al. [2] state that compared to pancreatic carcinomas, ampullary carcinomas have a significantly higher resectability rate and a much

the existence of liver metastases in the case of the vaterian ampulloma.

than in the case of primitive duodenal malignancies.

**3.9 Modifications of the biliary and pancreatic ducts**

choledoch duct that can be considered normal.

duct, i.e., up to 1.5 cm [1] (**Figure 9a, b**).

dochal dilation not exceed 1.5 cm.

space, as we described in the previous subchapters being normal.

**94**

*Changes in the bile duct in the ampulloma: Cholangio-MRI.*

space replacement at the level of the ampulla of Vater, which are not evidenced by the computed tomographic examination. He also argues that the magnetic resonance method is similar to ERCP from these points of view, but unlike the latter it is a noninvasive method.

If we compare it with the neoplasms of the head of the pancreas, we will notice that the dilation of the choledoch duct is reduced in terms of caliber, that is, in the case of pancreatic cephalic malignancies, the frequency of the presence of the choledoch dilation is much lower, of only about 30%, and dimensionally the choledoch rarely exceeds 1.5 cm.

Magnetic resonance exploration at the same time allows the study of the contours of the terminal part of the choledoch (**Figure 10**).

The existence of an irregular contour, particular to a neoplastic infiltration, cannot be discussed, considering that the Oddi sphincter usually represents an anatomical barrier in the superior extension of the tumor. The association of the terminal part of the choledoch narrowing with its irregular contours guides the diagnosis either toward a distal cholangiocarcinoma or in the case of a choledochal invasion by a pancreatic neoplasm.

This is the reason why the analysis of changes in the biliary duct was limited to dimensional evaluation.

Due to the anatomical position, the ampullar neoplasm also determines the dilation of the duct of Wirsung but only in a third of the cases. Semelka et al. [19] considers the presence of a high-caliber Wirsung as a nonspecific sign, accompanying the choledochal dilation, in a ratio similar to that found in our study.

**Figure 11.** *Lithiasis and bladder distension associated with a vaterian ampulloma.*
