**2. Radioimaging techniques of the duodenopancreatic region**

The involvement of the duodenum in the neighboring tumor pathology is explained primarily by the multitude of anatomical direct relationships that this organ has with the pancreas, liver, right kidney, colonic hepatic angle, etc.

Neoplasms of the vicinity that have been shown to be invasive in the duodenum are pancreatic tumors, regardless of the segment of this organ, hepatomas, gallbladder cancers, cholangiocarcinomas, malignancies of the right kidney, and colonic, retroperitoneal, as well as gastric duodenal lymphoma. Of these, the most common are the pancreatic neoplasms and the vaterian ampullomas [1].

From our experience, duodenal neoplasms can reach 13% of the total number of neoplasms of the pancreatic-duodenal region, most common being the invasive pancreatic cancer in the duodenum, with a percentage reaching up to 65%, followed by the vaterian ampullomas with a frequency of over 10% [1].

Talamini et al. [2] considers in a study conducted over a 28-year period that ampullary adenocarcinomas are the second most common malignancy in the periampullary region. In the present work, the vaterian ampullomas are in second place by frequency, after the pancreatic neoplasms, but in a ratio equal to the duodenal malignancies themselves.

The objectives of the radio-imagistic explorations in the vaterian ampulloma are:


**81**

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

the radiological study of the duodenal framework, especially the descending

By its anatomical location, any lesion at the level of the ampulla of Vater requires

Examination of the duodenum follows that of the stomach, which is why some aspects are difficult to highlight or elude the examiner due to technical defects or because he is distracted by the presence of other concomitant or associated lesions

The technique of examining the duodenum using simple contrast is that used in routine examination, following that of the esophagus and the stomach [1]. During this examination the patient ingests 240–360 ml of barium sulfate suspension in water, concentration 30–40%. It is preferable for the contrast agent to have small

adhesion of the contrast agent to the mucosal folds, it is recommended to associate a homogenizing agent such as methyl cellulose in the barium sulfate suspension. Preparation of the patient in the event of a suspected vaterian ampulloma should be done with great care, including an adequate diet, avoiding fermentable foods, long-molecule cellulose, and excess lipids, prohibiting any food intake 6–8 hours before examination, or secretion evacuation if the existence of a stenosis is a certainty. In order not to modify the functional duodenal mechano-secretory behavior, it is advisable to avoid the administration of drugs with implication in the

In this method of examination, the bulb and the rest of the duodenal frame are filled with contrast agent due to gravity and normal peristaltic movements of the stomach, the patient being in orthostatism, ventral decubitus, or right lateral

The technique of simple contrast duodenal exploration is a routine examination. It can be performed at any radiology office. However, the method also has drawbacks, the main ones being the overlap of the antrum and the sometimes-

Evaluation of the duodenum in double contrast may be part of the standard double contrast of the upper gastrointestinal tract. The examination starts with the carrying out of a seriography after ingesting a single barium swallow that allows a good lining of the digestive mucosa; this represents the mucographic time. At the same time, the exact position of the different portions of the gastric segment is noted.

. For a better

particles with a high dispersion degree of 4000–6000 particles/cm<sup>2</sup>

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

*2.1.1 Conventional radiological examination: barium meal*

**2.1 Radiological exploration**

of the esophagus or stomach.

*2.1.1.1 Simple contrast technique*

duodenopancreatic physiology.

insufficient distension of the duodenum.

This technique can be mainly achieved in two ways [1]:

a.Double-contrast hypotonic duodenography

*2.1.1.2.1 Double-contrast hypotonic duodenography*

*2.1.1.2 Double-contrast technique*

b.Probe duodenography

decubitus.

duodenum.

• The existence of possible subdiaphragmatic adenopathies

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

### **2.1 Radiological exploration**

*Gastrointestinal Stomas*

adenocarcinomas [1].

malignancies themselves.

autoplastic changes

• Modifications of the duodenal papilla

• Changes in size of the duodenal wall

with the lower third, but ectopic positions of the papilla are known, cranial at 1–2 cm below the bulb level, or caudal at the lower duodenal knee level [1].

their embryological origins and the different histological structures [1].

**2. Radioimaging techniques of the duodenopancreatic region**

are the pancreatic neoplasms and the vaterian ampullomas [1].

by the vaterian ampullomas with a frequency of over 10% [1].

The involvement of the duodenum in the neighboring tumor pathology is explained primarily by the multitude of anatomical direct relationships that this organ has with the pancreas, liver, right kidney, colonic hepatic angle, etc.

Neoplasms of the vicinity that have been shown to be invasive in the duodenum are pancreatic tumors, regardless of the segment of this organ, hepatomas, gallbladder cancers, cholangiocarcinomas, malignancies of the right kidney, and colonic, retroperitoneal, as well as gastric duodenal lymphoma. Of these, the most common

From our experience, duodenal neoplasms can reach 13% of the total number of neoplasms of the pancreatic-duodenal region, most common being the invasive pancreatic cancer in the duodenum, with a percentage reaching up to 65%, followed

Talamini et al. [2] considers in a study conducted over a 28-year period that ampullary adenocarcinomas are the second most common malignancy in the periampullary region. In the present work, the vaterian ampullomas are in second place by frequency, after the pancreatic neoplasms, but in a ratio equal to the duodenal

The objectives of the radio-imagistic explorations in the vaterian ampulloma are:

• Detection of the tumor lesion, providing information on the location, shape, dimensions, and contours of the space replacement process, as well as on the presence of any ulcerations or fistulas and the degree of lumen stenosis

• The state of the duodenal mucosa, insisting on the morphofunctional and

• The existence of modifications of the parenchymatous organs or segments of the digestive tract potentially involved in the mechanisms of tumor onset

• Extension of the ampullary lesion in the periduodenal space

or the degree of tumor invasion in the neighboring organs

• The existence of possible subdiaphragmatic adenopathies

A special place is occupied by the cancers of the ampulla of Vater, which are distinct entities, separate from those of the duodenum, although the anatomical location of the ampulla of Vater is at the level of the descending duodenum, due to

Neoplasms of the vaterian region, also known as vaterian ampulloma, may have as a starting point the cylindrical choledochal epithelium, the Wirsungian cubic epithelium, or the glandular epithelium of the papilla. Due to their origin in an epithelial type tissue structure, histopathologically these tumors are

**80**

#### *2.1.1 Conventional radiological examination: barium meal*

By its anatomical location, any lesion at the level of the ampulla of Vater requires the radiological study of the duodenal framework, especially the descending duodenum.

Examination of the duodenum follows that of the stomach, which is why some aspects are difficult to highlight or elude the examiner due to technical defects or because he is distracted by the presence of other concomitant or associated lesions of the esophagus or stomach.

#### *2.1.1.1 Simple contrast technique*

The technique of examining the duodenum using simple contrast is that used in routine examination, following that of the esophagus and the stomach [1]. During this examination the patient ingests 240–360 ml of barium sulfate suspension in water, concentration 30–40%. It is preferable for the contrast agent to have small particles with a high dispersion degree of 4000–6000 particles/cm<sup>2</sup> . For a better adhesion of the contrast agent to the mucosal folds, it is recommended to associate a homogenizing agent such as methyl cellulose in the barium sulfate suspension.

Preparation of the patient in the event of a suspected vaterian ampulloma should be done with great care, including an adequate diet, avoiding fermentable foods, long-molecule cellulose, and excess lipids, prohibiting any food intake 6–8 hours before examination, or secretion evacuation if the existence of a stenosis is a certainty. In order not to modify the functional duodenal mechano-secretory behavior, it is advisable to avoid the administration of drugs with implication in the duodenopancreatic physiology.

In this method of examination, the bulb and the rest of the duodenal frame are filled with contrast agent due to gravity and normal peristaltic movements of the stomach, the patient being in orthostatism, ventral decubitus, or right lateral decubitus.

The technique of simple contrast duodenal exploration is a routine examination. It can be performed at any radiology office. However, the method also has drawbacks, the main ones being the overlap of the antrum and the sometimesinsufficient distension of the duodenum.

#### *2.1.1.2 Double-contrast technique*

This technique can be mainly achieved in two ways [1]:


#### *2.1.1.2.1 Double-contrast hypotonic duodenography*

Evaluation of the duodenum in double contrast may be part of the standard double contrast of the upper gastrointestinal tract. The examination starts with the carrying out of a seriography after ingesting a single barium swallow that allows a good lining of the digestive mucosa; this represents the mucographic time. At the same time, the exact position of the different portions of the gastric segment is noted.

The double-contrast hypotonic duodenography can be obtained using two methods: the double-contrast method performed during the eso-gastro-duodenal examination, using glucagon and a gaseous potion as a pharmacodynamics, or the hypotonic duodenography in which the patient is given an antispastic after administration of the contrast agent.

In the first method, the double-contrast phase can be obtained by inducing a short-term hypotonia by injecting 0.1 mg of glucagon IV at the beginning of the examination, after which the patient ingests the gaseous agent, respectively, a mixture of citric acid and sodium bicarbonate, with 10 ml of water and highdensity barium sulfate, of about 200–250 wt/vol%. After 5–10 min, during which the esophagus and stomach are examined, the hypotonic effect of the glucagon is finished so that the air and barium pass easily through the pylorus and reach the duodenum. The positioning of the patient in ventral and left posterior oblique decubitus fills the duodenal bulb with high-density barium. The compression performed in ventral decubitus is not as useful as in simple contrast due to the increased barium density. We can obtain a series of double-contrast images of both the bulb and duodenal frame in the right anterior oblique position after the patient ingests 240 ml of low-density barium suspension.

The method has maximum reliability for examining the stomach, duodenal bulb, and possibly the descending duodenum. It has the disadvantage that it does not allow a good assessment of the state of the duodenal mucosa, and the overlaps of the antral portion cannot always be excluded. Also, the two fractions of barium suspension can be mixed, which may induce interpretation errors.

In the second method, the exploration is required to be carried out quickly; the patient should swallow 100–150 ml of barium sulfate suspension. The patient is placed in dorsal decubitus, then the antispastic is injected, after which the subject is immediately repositioned in the right lateral decubitus, a position in which he ingests the effervescent potion through a pipette or cannula. The contrast agent enters the duodenum which is already in hypotonic state. The duodenum in repletion and hypotonia is radiographed in this position and in several incidences in left posterior oblique position. The duodenal distension fades in dorsal decubitus and the root of the mesentery no longer ensuring its compression on D3. An accumulation of contrast agents is observed in the bulb. In this situation it is sufficient to raise the table by 30° in order to evacuate it and to be able to carry out the correct seriographies on the duodenum, especially the descending portion and the bulb, which, due to the hypotony, expands with the gas released by the effervescent potion.

There is also a method that can prevent overlapping of the gastric antral. This consists of introducing an Einhorn probe into the duodenum and through it 10 ml of xylin, with high viscosity administered at body temperature, which can achieve a hypotonia of the duodenum after a few minutes. Instead of xylin, scobutil can be used, administered intravenously. The hypotonic effect occurs in about 15–30 min. Barium sulfate suspension administration on the probe allows the duodenal framework to be completely opacified.

The method also has disadvantages. Antispasmodics alter the kinetics, tonicity, and duodenal secretion. During this time, due to the induced changes, the duodenal stasis is accentuated. For this reason, the low-density barium sulfate suspension is mixed with the stasis liquid, and if we do not use a homogenizing agent, bubbles may appear at the air-liquid interface that can fix themselves on the mucous folds, leading to an erroneous diagnosis. The method gives exclusively morphological information which means an incomplete radiological diagnosis. Due to hypotonia and hypokinesia, any stiffness and the study of autoplasty cannot be properly appreciated.

**83**

this level.

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

This method is used when the radiologist is interested in studying the duodenal framework or when, following previous examinations, the suspicion of a strictly

of air into the duodenum. The insufflation is gradual, under

The examination is performed in several positions and incidences, being mandatory to start from dorsal and right oblique anterior decubitus, continuing with the ventral and oblique posterior left decubitus, performing serial X-rays. Highlighting any anomalies requires X-rays of different incidences and intermediate positions,

The results are good, but they require a perfect knowledge of the anatomy of the region and the normal radiological aspect, since it differs from the known radiologi-

The main advantage of the method is that it is possible to avoid overlaps with other segments of the digestive tract, especially with the gastric antrum. Also, by this method, small lesions of the mucosa can be detected, which can elude the examiner in simple contrast or in double contrast performed during the eso-gastroduodenal examination. Antispastic substances that modify normal duodenal tonicity and kinetics and which modify duodenal secretion are not used. In this way the examination can also provide functional data of the investigated segment. The examination is unpleasant for the patient due to the need to introduce the probe; therefore it is advisable that the examination be preceded by a brief discussion with the subject, in which the technique and the need for the examination will be explained to him. The crossing of the pylorus cannot always be realized; at position changes, a withdrawal of the probe into the stomach can occur, an incident that can also occur at a sharp intake of breath. This can be avoided if the examination is performed using a probe with a balloon at the end, which will set it to the desired level. The advantage of using such a probe is to prevent airflow back into the gastric antrum. The time required for the examination is long. The technique is not of first intention, usually being performed only when there are clear clinical indications about

The radiological techniques described can assess the overall duodenal morphology. Under distension and hypotony, the duodenal frame as a whole appears slightly enlarged. The examination allows to identify the duodenal anatomical segments and their possible anatomical variants (reverse V duodenum, mobile duodenum, small duodenal frame, surrounding the bulb, as in the case of gastric ptosis).

On the postero-external border of the descending duodenum, it is possible to highlight a possible imprint, due to the direct relations with the right kidney at

An enteral probe is used to perform this technique. The probe is introduced nasally or orally after the pharyngeal mucosa is embrocated or anesthetic solution is gargled. The distal end of the probe should reach the mid-level of D2; insertion of the probe into the stomach is done with the patient in a seated position, after which the patient lies in a right lateral decubitus and the probe is passed through the pylorus. To avoid coiling the probe, it is good to use either a probe weighted at the end or a metallic, soft, and flexible guide. The positioning of the probe will be done under radioscopic control. Then the duodenum is aspirated, after which the barium suspension is introduced under pressure, in a volume of about 30–50 ml. The suspension of barium sulfate must be fluid, homogeneous, and very adherent. It is indicated that the barium sulfate has a high dispersion degree and the suspension contains a methyl cellulose-type surfactant. Double contrast is obtained by blow-

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

localized lesion at this level is raised.

radioscopic control during examination.

being able to better highlight the lesion.

the presence of a space replacement process.

ing about 80–100 cm3

cal anatomy.

*2.1.1.2.2 Selective duodenography or probe duodenography*

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

#### *2.1.1.2.2 Selective duodenography or probe duodenography*

*Gastrointestinal Stomas*

tration of the contrast agent.

ingests 240 ml of low-density barium suspension.

The double-contrast hypotonic duodenography can be obtained using two methods: the double-contrast method performed during the eso-gastro-duodenal examination, using glucagon and a gaseous potion as a pharmacodynamics, or the hypotonic duodenography in which the patient is given an antispastic after adminis-

In the first method, the double-contrast phase can be obtained by inducing a short-term hypotonia by injecting 0.1 mg of glucagon IV at the beginning of the examination, after which the patient ingests the gaseous agent, respectively, a mixture of citric acid and sodium bicarbonate, with 10 ml of water and highdensity barium sulfate, of about 200–250 wt/vol%. After 5–10 min, during which the esophagus and stomach are examined, the hypotonic effect of the glucagon is finished so that the air and barium pass easily through the pylorus and reach the duodenum. The positioning of the patient in ventral and left posterior oblique decubitus fills the duodenal bulb with high-density barium. The compression performed in ventral decubitus is not as useful as in simple contrast due to the increased barium density. We can obtain a series of double-contrast images of both the bulb and duodenal frame in the right anterior oblique position after the patient

The method has maximum reliability for examining the stomach, duodenal bulb, and possibly the descending duodenum. It has the disadvantage that it does not allow a good assessment of the state of the duodenal mucosa, and the overlaps of the antral portion cannot always be excluded. Also, the two fractions of barium

In the second method, the exploration is required to be carried out quickly; the patient should swallow 100–150 ml of barium sulfate suspension. The patient is placed in dorsal decubitus, then the antispastic is injected, after which the subject is immediately repositioned in the right lateral decubitus, a position in which he ingests the effervescent potion through a pipette or cannula. The contrast agent enters the duodenum which is already in hypotonic state. The duodenum in repletion and hypotonia is radiographed in this position and in several incidences in left posterior oblique position. The duodenal distension fades in dorsal decubitus and the root of the mesentery no longer ensuring its compression on D3. An accumulation of contrast agents is observed in the bulb. In this situation it is sufficient to raise the table by 30° in order to evacuate it and to be able to carry out the correct seriographies on the duodenum, especially the descending portion and the bulb, which, due to the hypotony, expands with the gas released by the

There is also a method that can prevent overlapping of the gastric antral. This consists of introducing an Einhorn probe into the duodenum and through it 10 ml of xylin, with high viscosity administered at body temperature, which can achieve a hypotonia of the duodenum after a few minutes. Instead of xylin, scobutil can be used, administered intravenously. The hypotonic effect occurs in about 15–30 min. Barium sulfate suspension administration on the probe allows the duodenal frame-

The method also has disadvantages. Antispasmodics alter the kinetics, tonicity, and duodenal secretion. During this time, due to the induced changes, the duodenal stasis is accentuated. For this reason, the low-density barium sulfate suspension is mixed with the stasis liquid, and if we do not use a homogenizing agent, bubbles may appear at the air-liquid interface that can fix themselves on the mucous folds, leading to an erroneous diagnosis. The method gives exclusively morphological information which means an incomplete radiological diagnosis. Due to hypotonia and hypokinesia, any stiffness and the study of autoplasty cannot be properly

suspension can be mixed, which may induce interpretation errors.

**82**

appreciated.

effervescent potion.

work to be completely opacified.

This method is used when the radiologist is interested in studying the duodenal framework or when, following previous examinations, the suspicion of a strictly localized lesion at this level is raised.

An enteral probe is used to perform this technique. The probe is introduced nasally or orally after the pharyngeal mucosa is embrocated or anesthetic solution is gargled. The distal end of the probe should reach the mid-level of D2; insertion of the probe into the stomach is done with the patient in a seated position, after which the patient lies in a right lateral decubitus and the probe is passed through the pylorus. To avoid coiling the probe, it is good to use either a probe weighted at the end or a metallic, soft, and flexible guide. The positioning of the probe will be done under radioscopic control. Then the duodenum is aspirated, after which the barium suspension is introduced under pressure, in a volume of about 30–50 ml. The suspension of barium sulfate must be fluid, homogeneous, and very adherent. It is indicated that the barium sulfate has a high dispersion degree and the suspension contains a methyl cellulose-type surfactant. Double contrast is obtained by blowing about 80–100 cm3 of air into the duodenum. The insufflation is gradual, under radioscopic control during examination.

The examination is performed in several positions and incidences, being mandatory to start from dorsal and right oblique anterior decubitus, continuing with the ventral and oblique posterior left decubitus, performing serial X-rays. Highlighting any anomalies requires X-rays of different incidences and intermediate positions, being able to better highlight the lesion.

The results are good, but they require a perfect knowledge of the anatomy of the region and the normal radiological aspect, since it differs from the known radiological anatomy.

The main advantage of the method is that it is possible to avoid overlaps with other segments of the digestive tract, especially with the gastric antrum. Also, by this method, small lesions of the mucosa can be detected, which can elude the examiner in simple contrast or in double contrast performed during the eso-gastroduodenal examination. Antispastic substances that modify normal duodenal tonicity and kinetics and which modify duodenal secretion are not used. In this way the examination can also provide functional data of the investigated segment.

The examination is unpleasant for the patient due to the need to introduce the probe; therefore it is advisable that the examination be preceded by a brief discussion with the subject, in which the technique and the need for the examination will be explained to him. The crossing of the pylorus cannot always be realized; at position changes, a withdrawal of the probe into the stomach can occur, an incident that can also occur at a sharp intake of breath. This can be avoided if the examination is performed using a probe with a balloon at the end, which will set it to the desired level. The advantage of using such a probe is to prevent airflow back into the gastric antrum.

The time required for the examination is long. The technique is not of first intention, usually being performed only when there are clear clinical indications about the presence of a space replacement process.

The radiological techniques described can assess the overall duodenal morphology. Under distension and hypotony, the duodenal frame as a whole appears slightly enlarged. The examination allows to identify the duodenal anatomical segments and their possible anatomical variants (reverse V duodenum, mobile duodenum, small duodenal frame, surrounding the bulb, as in the case of gastric ptosis).

On the postero-external border of the descending duodenum, it is possible to highlight a possible imprint, due to the direct relations with the right kidney at this level.

Duodenal distension is exercised up to the level of its horizontal portion, immediately after the lower knee, when the examination is performed in ventral and oblique posterior left decubitus, being determined by the compression of the mesenter's root over D3; in dorsal decubitus the compression is attenuated.

In dorsal decubitus the large papilla is visualized as a round-oval or oval transparency, contoured by the contrast substance. This area corresponds to the intramural pathway of the choledoch. The surrounding, well-visualized folds can converge into a single longitudinal fold or a bifid fold. The small papilla is rarely seen as a round lacunar image, with a diameter of about 5 mm, located cranially and medially to the large papilla.

In lateral decubitus, the longitudinal fold is highlighted on the endoluminal face, and the external duodenal contour becomes rectilinear due to the distension that erases the connivent valves. At the place of formation of the longitudinal fold, toward the tuber, a notch can be distinguished, which corresponds to the choledochian sphincter at this level. The small papilla is sometimes viewed as a notch located cranially to the large papilla.

Conventional radiological techniques represent at this time methods that are really historical, computed tomography replacing almost all of them.

#### *2.1.2 Computed tomography*

Technological progress (much shorter scanning time, better spatial resolution) and the new adapted examination protocols allow accurate study of the digestive wall and extra-parietal lesion extension [1, 3–8].

The main problem is obtaining an optimal distension of the duodenum in order to be able to correctly estimate the thickness of its wall, which is the most important computed tomography criterion of normality.

The duodenum is the most difficult region to examine due to the difficulty of obtaining adequate opacity, this being determined by the accelerated transport of water into the lumen, the water that dilutes the contrast agent.

Therefore, for the study of the duodenum, in fact of the entire upper digestive floor, the CT scan must be preceded by the ingestion of 600 ml of iodinated, watersoluble contrast substance, in a dilution of 2–3% approx. 5–10 min beforehand. IV antispastics can also be associated, which allow for a good study of the duodenal framework and the dissociation of the pancreas head. The exclusive use of air distension, as well as the use of simple water in combination with gastroduodenal hypotonia, increases the quality of parietography. The normal thickness of the duodenal wall is considered to be 3–4 mm.

The use of antispasmodics administered IV may diminish the artifacts generated by peristalsis, but due to the current ability to use a scanning time of less than 5 seconds, it is no longer of interest.

The intravenous administration of the iodinated contrast agent should be systematic for assessing the iodophilia of the lesion and for studying the relationships with the neighboring structures. It is also used to assess the extent of the tumor lesion, by determining the metastases, as well as to assess the existence of any abnormalities in the parenchymal organs, in relation to the duodenal disease or simultaneous with it.

In view of the frequent involvement of the duodenum in the neighboring tumors, especially those in the pancreas, in the vaterian ampulloma, etc., performing the computed tomographic examination both native and with contrast agent becomes almost obligatory. Thus, computed tomography becomes the essential method of establishing the starting point in duodenal tumor determinations, at the same time achieving the pre-therapeutic balance of the lesion extension.

**85**

*2.2.2 MRI*

abdominal viscera.

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

The administration of the intravenous contrast substance allows at the same time to opacify the vascular landmarks of this region, particularly the renal vein, inferior vena cava, as well as of the superior splenic and mesenteric vessels. The possibility of conducting the spiral computed tomographic examination gives almost overlap-

The acquisition is made through contiguous sections, 5 mm thick, but 3 mm sections can be used to allow analysis of small organs or to obtain details on the lesion. The patient is initially placed in dorsal decubitus. The computed tomographic examination can be complemented, depending on the needs, with sections performed in ventral decubitus, lateral decubitus, sections that highlight the digestive connection of large tumor masses, and their dissociation from the adjacent viscera. The use of some image processing techniques allows biplane or spatial reconstruction of the bile ducts and the duct of Wirsung and is usually used to detect

Ultrasonography as an imaging exploration of the duodenum is not a primary intention technique [1, 9]. It can be performed transabdominally—routine examination in which the primary information is related to the pathology of the parenchymal organs—and echoendoscopy, a method with maximum reliability on the pathology of the duodenal wall and the eventual differential diagnosis between

If the first technique of ultrasonographic exploration has a general addressability and accessibility, not requiring a special training of the patient, the second technique requires special equipment and a special skillset, being used especially by the doctors performing endoscopy, as a complement to a routine endoscopic examination. Transparietal ultrasound can reveal changes of the duodenal peristaltic, duodenal stasis, or parietal duodenal infiltration. Complementing the examination with the Doppler technique may bring additional information to the duodenal tumor pathology. Probes of at least 5 MHz should be used for better lesion detection. Ultrasound examination of the pancreas and distal bile ducts is the primary

The specificity and sensitivity of the method depend on the quality of the equip-

MRI scanning is not a primary imaging technique for patients with suspected tumor pathology of the duodenum-pancreatic region [1, 10–17]. The possibility of clearly highlighting soft structures and multiplane images makes this method superior to computer tomographic exploration. Magnetic resonance highlights both

The body antenna is most commonly used. The spin echo sequences are constituted as reference sequences. T1-weighted sequences with short TR and TE allow excellent spatial resolution, providing the best morphological information of

T2-weighted sequences with long TR and TE have a good resolution in contrast and allow a more reliable tissue study. Given the relatively long acquisition time, at least 3 min, FLASH or SPGR gradient echo sequences are used more frequently,

ment, but in particular, on the experience of the one using the method.

the duodenal wall and the intraluminal duodenal content.

although they have a lower signal-to-noise ratio.

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

ping information with the angiographic examination.

lesions of distal bile ducts and in the vaterian ampulloma.

primitive duodenal lesions/invasion by contiguity.

method for any suspected tumor pathology.

**2.2 Imaging explorations**

*2.2.1 Ultrasound*

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

The administration of the intravenous contrast substance allows at the same time to opacify the vascular landmarks of this region, particularly the renal vein, inferior vena cava, as well as of the superior splenic and mesenteric vessels. The possibility of conducting the spiral computed tomographic examination gives almost overlapping information with the angiographic examination.

The acquisition is made through contiguous sections, 5 mm thick, but 3 mm sections can be used to allow analysis of small organs or to obtain details on the lesion.

The patient is initially placed in dorsal decubitus. The computed tomographic examination can be complemented, depending on the needs, with sections performed in ventral decubitus, lateral decubitus, sections that highlight the digestive connection of large tumor masses, and their dissociation from the adjacent viscera.

The use of some image processing techniques allows biplane or spatial reconstruction of the bile ducts and the duct of Wirsung and is usually used to detect lesions of distal bile ducts and in the vaterian ampulloma.

#### **2.2 Imaging explorations**

#### *2.2.1 Ultrasound*

*Gastrointestinal Stomas*

medially to the large papilla.

*2.1.2 Computed tomography*

located cranially to the large papilla.

wall and extra-parietal lesion extension [1, 3–8].

computed tomography criterion of normality.

duodenal wall is considered to be 3–4 mm.

5 seconds, it is no longer of interest.

simultaneous with it.

water into the lumen, the water that dilutes the contrast agent.

Duodenal distension is exercised up to the level of its horizontal portion, immediately after the lower knee, when the examination is performed in ventral and oblique posterior left decubitus, being determined by the compression of the mesenter's root over D3; in dorsal decubitus the compression is attenuated. In dorsal decubitus the large papilla is visualized as a round-oval or oval transparency, contoured by the contrast substance. This area corresponds to the intramural pathway of the choledoch. The surrounding, well-visualized folds can converge into a single longitudinal fold or a bifid fold. The small papilla is rarely seen as a round lacunar image, with a diameter of about 5 mm, located cranially and

In lateral decubitus, the longitudinal fold is highlighted on the endoluminal face, and the external duodenal contour becomes rectilinear due to the distension that erases the connivent valves. At the place of formation of the longitudinal fold, toward the tuber, a notch can be distinguished, which corresponds to the choledochian sphincter at this level. The small papilla is sometimes viewed as a notch

Conventional radiological techniques represent at this time methods that are

Technological progress (much shorter scanning time, better spatial resolution) and the new adapted examination protocols allow accurate study of the digestive

The main problem is obtaining an optimal distension of the duodenum in order to be able to correctly estimate the thickness of its wall, which is the most important

The duodenum is the most difficult region to examine due to the difficulty of obtaining adequate opacity, this being determined by the accelerated transport of

Therefore, for the study of the duodenum, in fact of the entire upper digestive floor, the CT scan must be preceded by the ingestion of 600 ml of iodinated, watersoluble contrast substance, in a dilution of 2–3% approx. 5–10 min beforehand. IV antispastics can also be associated, which allow for a good study of the duodenal framework and the dissociation of the pancreas head. The exclusive use of air distension, as well as the use of simple water in combination with gastroduodenal hypotonia, increases the quality of parietography. The normal thickness of the

The use of antispasmodics administered IV may diminish the artifacts generated by peristalsis, but due to the current ability to use a scanning time of less than

The intravenous administration of the iodinated contrast agent should be systematic for assessing the iodophilia of the lesion and for studying the relationships with the neighboring structures. It is also used to assess the extent of the tumor lesion, by determining the metastases, as well as to assess the existence of any abnormalities in the parenchymal organs, in relation to the duodenal disease or

In view of the frequent involvement of the duodenum in the neighboring tumors, especially those in the pancreas, in the vaterian ampulloma, etc., performing the computed tomographic examination both native and with contrast agent becomes almost obligatory. Thus, computed tomography becomes the essential method of establishing the starting point in duodenal tumor determinations, at the

same time achieving the pre-therapeutic balance of the lesion extension.

really historical, computed tomography replacing almost all of them.

**84**

Ultrasonography as an imaging exploration of the duodenum is not a primary intention technique [1, 9]. It can be performed transabdominally—routine examination in which the primary information is related to the pathology of the parenchymal organs—and echoendoscopy, a method with maximum reliability on the pathology of the duodenal wall and the eventual differential diagnosis between primitive duodenal lesions/invasion by contiguity.

If the first technique of ultrasonographic exploration has a general addressability and accessibility, not requiring a special training of the patient, the second technique requires special equipment and a special skillset, being used especially by the doctors performing endoscopy, as a complement to a routine endoscopic examination.

Transparietal ultrasound can reveal changes of the duodenal peristaltic, duodenal stasis, or parietal duodenal infiltration. Complementing the examination with the Doppler technique may bring additional information to the duodenal tumor pathology. Probes of at least 5 MHz should be used for better lesion detection.

Ultrasound examination of the pancreas and distal bile ducts is the primary method for any suspected tumor pathology.

The specificity and sensitivity of the method depend on the quality of the equipment, but in particular, on the experience of the one using the method.

#### *2.2.2 MRI*

MRI scanning is not a primary imaging technique for patients with suspected tumor pathology of the duodenum-pancreatic region [1, 10–17]. The possibility of clearly highlighting soft structures and multiplane images makes this method superior to computer tomographic exploration. Magnetic resonance highlights both the duodenal wall and the intraluminal duodenal content.

The body antenna is most commonly used. The spin echo sequences are constituted as reference sequences. T1-weighted sequences with short TR and TE allow excellent spatial resolution, providing the best morphological information of abdominal viscera.

T2-weighted sequences with long TR and TE have a good resolution in contrast and allow a more reliable tissue study. Given the relatively long acquisition time, at least 3 min, FLASH or SPGR gradient echo sequences are used more frequently, although they have a lower signal-to-noise ratio.

The use of fat saturation sequences reduces respiratory and structural artifacts but has a longer acquisition time.

For a complete study, it is absolutely necessary to use sequences specific to the study of vessels.

In case of suspicion of an ampullary tumor, MRCP is mandatory. In the last three decades, this technique has become absolutely necessary in the diagnosis of a biliary duct obstruction, obstruction which is caused at the right level by an ampullary tumor. MRCP is a diagnostic method, while ERCP remained a rather interventional method. T2 hyperintensive sequences are used, which make the content of both biliary and Wirsung ducts white in contrast to the rest of the structures. Sequences with thin sections (3–5 mm), which have the purpose of an MIP type reconstruction, and sequences with thick sections (30–50 mm), which have a short acquisition time (<5 s) and which are performed in multiple planes, are used. The acquisitions are made in the coronal and oblique coronal plane. If we refer strictly to MRCP, the administration of the contrast agent is not obligatory, but in the case of the ampullary tumors, this is a complementary sequence that is associated with the abdominal MRI scan. The MRCP highlights the contents and implicitly the size of the bile ducts and the duct of Wirsung, but does not give details on their wall, which was done by an abdominal MRI scan.

However, with MRCP you can administer negative oral contrast agent that reduces the hypersignal of gastric and intestinal fluids, thus increasing the contrast of the contents of the bile ducts and the duct of Wirsung.

In addition, the MRCP technique can provide information on the pancreatic function. This is achieved by the intravenous administration of secretin which has the role of increasing the pancreatic exocrine function, so it will increase the flow and quantity of pancreatic juice, and implicitly it will expand to the maximum the pancreatic ducts, thus being able to highlight both the main duct and the secondary ones.

The axial plane examination constitutes the reference sequences of the examination. In order to specify the exact anatomical reports or for the study of the vessels, frontal and coronal acquisitions are also made.

The mucosal study is performed using water per os or more reliably through the probe. The study of parietal changes requires sequences with paramagnetic contrast products.

The MR exploration, due to the possibilities of acquisition, processing, and reconstruction of the images, allows the study of the biliary ducts, having major importance in the tumor pathology of the duodenopancreatic region and the study dedicated to the vessels related to this region.

### **3. Semiology of ampulla of Vater neoplasms**

The histological structure comprises the tunics of the duodenal wall but also a separate muscular entity—the Oddi sphincter [1]. In terms of structure, the smooth musculature of the Oddi sphincter differs both anatomically and embryologically from the surrounding duodenal musculature. Its mechanical and electrical activity is independent and different from that of the duodenal muscle, but it is integrated into myogenic, regulating mechanisms through innervation and hormonal activity.

The mucus of the Vater papilla forms a complicated system of folds whose main function is the creation of "valves" with anti-reflux role, especially for biliary drainage. The ampulla of Vater is visible during the radiological examination in double contrast of the duodenum, being recognizable due to the presence of a superior fold and the longitudinal fold, located on the posteromedial face of the descending

**87**

**Figure 1.**

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

duodenum. Frequently at this level, there are two oblique folds. In conventional radiological exploration, in simple contrast, visualization of the papilla is much

level of the descending duodenum, approximately in the middle of it.

**3.1 Radioimaging changes found in ampulla of Vater neoplasms**

in diagnosing cancers of the ampulla of Vater (**Figures 2** and **3**).

probability of a vaterian ampulloma by Caroli et al. [18].

radiological sign in this study as well.

*Vaterian ampulloma: Conventional exploration.*

but especially in interventional radiology and endoscopy.

These are briefly some of the anatomical, functional, and embryological arguments that cause the tumor pathology of the ampulla of Vater to be treated separately from that of the duodenum, although the location of the Vater papilla is at the

These considerations have a very important practical substrate. According to Dudiak et al. [7], there is a direct interrelation between the anatomy and the embryology of the papilla and the radiological and endoscopic exploration possibilities,

Regardless of the radioimaging method used, in the case of neoplasms of the ampulla of Vater, several signs that can guide the diagnosis can be highlighted

Computed tomography and magnetic resonance imaging are particularly reliable

Next we tried an analysis of these signs, direct or indirect, which alone or associ-

ated would help the radiologist to diagnose the lesion as accurately as possible.

The classical radiological appearance of the ampullar neoplasm consists of a lacunar image located in the region of the ampulla of Vater, which can be located intraluminally or marginally, on the internal contour of the second portion of the duodenum. This radiological change is also mentioned as a radiological sign of

The lacuna, as an elementary change in the radiological diagnosis of the ampulla, has lost its importance with the advent of other techniques of radioimaging investigation. In view of its existence, relatively frequently encountered today in standard radiological exploration protocols, we introduced the analysis of this

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

more difficult.

(**Figure 1**).

**3.2 The lacuna**

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

duodenum. Frequently at this level, there are two oblique folds. In conventional radiological exploration, in simple contrast, visualization of the papilla is much more difficult.

These are briefly some of the anatomical, functional, and embryological arguments that cause the tumor pathology of the ampulla of Vater to be treated separately from that of the duodenum, although the location of the Vater papilla is at the level of the descending duodenum, approximately in the middle of it.

These considerations have a very important practical substrate. According to Dudiak et al. [7], there is a direct interrelation between the anatomy and the embryology of the papilla and the radiological and endoscopic exploration possibilities, but especially in interventional radiology and endoscopy.

#### **3.1 Radioimaging changes found in ampulla of Vater neoplasms**

Regardless of the radioimaging method used, in the case of neoplasms of the ampulla of Vater, several signs that can guide the diagnosis can be highlighted (**Figure 1**).

Computed tomography and magnetic resonance imaging are particularly reliable in diagnosing cancers of the ampulla of Vater (**Figures 2** and **3**).

Next we tried an analysis of these signs, direct or indirect, which alone or associated would help the radiologist to diagnose the lesion as accurately as possible.

#### **3.2 The lacuna**

*Gastrointestinal Stomas*

study of vessels.

an abdominal MRI scan.

secondary ones.

products.

but has a longer acquisition time.

The use of fat saturation sequences reduces respiratory and structural artifacts

For a complete study, it is absolutely necessary to use sequences specific to the

However, with MRCP you can administer negative oral contrast agent that reduces the hypersignal of gastric and intestinal fluids, thus increasing the contrast

In addition, the MRCP technique can provide information on the pancreatic function. This is achieved by the intravenous administration of secretin which has the role of increasing the pancreatic exocrine function, so it will increase the flow and quantity of pancreatic juice, and implicitly it will expand to the maximum the pancreatic ducts, thus being able to highlight both the main duct and the

The axial plane examination constitutes the reference sequences of the examination. In order to specify the exact anatomical reports or for the study of the vessels,

The mucosal study is performed using water per os or more reliably through the probe. The study of parietal changes requires sequences with paramagnetic contrast

The MR exploration, due to the possibilities of acquisition, processing, and reconstruction of the images, allows the study of the biliary ducts, having major importance in the tumor pathology of the duodenopancreatic region and the study

The histological structure comprises the tunics of the duodenal wall but also a separate muscular entity—the Oddi sphincter [1]. In terms of structure, the smooth musculature of the Oddi sphincter differs both anatomically and embryologically from the surrounding duodenal musculature. Its mechanical and electrical activity is independent and different from that of the duodenal muscle, but it is integrated into myogenic, regulating mechanisms through innervation and hormonal activity. The mucus of the Vater papilla forms a complicated system of folds whose main function is the creation of "valves" with anti-reflux role, especially for biliary drainage. The ampulla of Vater is visible during the radiological examination in double contrast of the duodenum, being recognizable due to the presence of a superior fold and the longitudinal fold, located on the posteromedial face of the descending

of the contents of the bile ducts and the duct of Wirsung.

frontal and coronal acquisitions are also made.

dedicated to the vessels related to this region.

**3. Semiology of ampulla of Vater neoplasms**

In case of suspicion of an ampullary tumor, MRCP is mandatory. In the last three decades, this technique has become absolutely necessary in the diagnosis of a biliary duct obstruction, obstruction which is caused at the right level by an ampullary tumor. MRCP is a diagnostic method, while ERCP remained a rather interventional method. T2 hyperintensive sequences are used, which make the content of both biliary and Wirsung ducts white in contrast to the rest of the structures. Sequences with thin sections (3–5 mm), which have the purpose of an MIP type reconstruction, and sequences with thick sections (30–50 mm), which have a short acquisition time (<5 s) and which are performed in multiple planes, are used. The acquisitions are made in the coronal and oblique coronal plane. If we refer strictly to MRCP, the administration of the contrast agent is not obligatory, but in the case of the ampullary tumors, this is a complementary sequence that is associated with the abdominal MRI scan. The MRCP highlights the contents and implicitly the size of the bile ducts and the duct of Wirsung, but does not give details on their wall, which was done by

**86**

The classical radiological appearance of the ampullar neoplasm consists of a lacunar image located in the region of the ampulla of Vater, which can be located intraluminally or marginally, on the internal contour of the second portion of the duodenum. This radiological change is also mentioned as a radiological sign of probability of a vaterian ampulloma by Caroli et al. [18].

The lacuna, as an elementary change in the radiological diagnosis of the ampulla, has lost its importance with the advent of other techniques of radioimaging investigation. In view of its existence, relatively frequently encountered today in standard radiological exploration protocols, we introduced the analysis of this radiological sign in this study as well.

**Figure 1.** *Vaterian ampulloma: Conventional exploration.*

**Figure 2.** *Vaterian ampulloma: CT exploration.*

**Figure 3.** *Vaterian ampulloma: MRI exploration.*

The lacuna can be highlighted in a percentage of less than 40% of the total cases of malignancies of the pancreatic-duodenal region [1] (**Figure 4**).

The standardized criteria of malignancy of a lacuna considers that it must have an irregular and erased contour; it must interrupt the folds, due to peritumoral malignant infiltration, coexisting with the presence of possible superficial ulcerations; and, in principle, it is larger than 2–3 cm. Although it is known that ampullary carcinomas do not reach overly large sizes until the moment of diagnosis, due to the relatively rapid installation of jaundice, the specialized literature attests the presence of areas of neoplastic cells in the structure of a vaterian adenoma, even of very small dimensions.

Because of this, but also due to the fact that a conventional radiological examination, no matter how well performed, cannot accomplish the benign-malignant differentiation in the case of ampullary tumors, we consider that only the contours and dimensions of the ampullae should be analyzed.

From a dimensional point of view, we classified the lacunas in the ampulloma in gaps with diameters between 1–3, 3–5, and over 5 cm.

It is proven that this neoplastic entity is in the form of a small space replacement process, below 3 cm in a percentage of 70%, the remaining 30% being tumors with dimensions between 3 and 5 cm. You can also see the absence of space replacement processes with dimensions over 5 cm.

Semelka et al. [19], following a study carried out over a 2-year period, regarding the ampullary carcinoma, have concluded that the dimensions of this type of neoplasia do not exceed 5.5 cm.

**89**

aggressiveness.

*The lacuna in a vaterian ampulloma.*

**Figure 4.**

computed tomographic exploration.

presented at the beginning of this subchapter.

insertion of the biliary and pancreatic ducts remains fixed.

enlargement of the head of the pancreas, whatever the cause.

**3.3 The presence of the Frostberg sign**

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

These are arguments in favor of the authors' assertions that vaterian carcinoma

Also, the reduced size and the histopathological nature of the ampullary adenocarcinoma lead to the conclusion that this **type** of neoplasm is one with reduced

The conventional radiological examination is excellently complemented by the computed tomographic exploration or by magnetic resonance that can detect space replacement processes with dimensions up to 1 cm. These are seen as small occurrences in the duodenal lumen, which cannot be detected by the standard radiological examination. The report of detection of space replacement processes by the two associated methods, the examination of the duodenum in double-contrast and computed tomography or MRI, actually highlights a double number of processes of space replacement at the level of the ampulla of Vater, regardless of its size. Comparison of these two exploration techniques with each other, but also with endoscopic exploration, reveals a greater specificity of magnetic resonance exploration than

Semelka et al. [19], in a study on the reliability of radiological and imaging scanning techniques versus ERCP, concluded on the superior specificity of magnetic resonance scanning compared to computed tomography. At the same time, considering the potential risks of retrograde endoscopic cholangiopancreatography, it recommends MRI as the diagnostic method with the highest degree of specificity. In conclusion, we have considered all the radio-imagistic methods of detecting the process of space replacement in the case of the vaterian ampullomas, which we

The Frostberg sign, also known as the inverted "3" sign (**Figure 5**), represents,

From the etiological point of view, this radiological modification is nonspecific; it can be present both in the malignant tumors of the ampulla of Vater and in any

from a radiological point of view, a semiological contour modification, which translates into an enlargement of the duodenal papilla, in the center of which the

is largely the result of malignant transformation of an adenoma.

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

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

**Figure 4.** *The lacuna in a vaterian ampulloma.*

*Gastrointestinal Stomas*

**Figure 2.**

**Figure 3.**

*Vaterian ampulloma: CT exploration.*

*Vaterian ampulloma: MRI exploration.*

The lacuna can be highlighted in a percentage of less than 40% of the total cases

The standardized criteria of malignancy of a lacuna considers that it must have an irregular and erased contour; it must interrupt the folds, due to peritumoral malignant infiltration, coexisting with the presence of possible superficial ulcerations; and, in principle, it is larger than 2–3 cm. Although it is known that ampullary carcinomas do not reach overly large sizes until the moment of diagnosis, due to the relatively rapid installation of jaundice, the specialized literature attests the presence of areas of neoplastic cells in the structure of a vaterian adenoma, even of

Because of this, but also due to the fact that a conventional radiological examination, no matter how well performed, cannot accomplish the benign-malignant differentiation in the case of ampullary tumors, we consider that only the contours

From a dimensional point of view, we classified the lacunas in the ampulloma in

It is proven that this neoplastic entity is in the form of a small space replacement process, below 3 cm in a percentage of 70%, the remaining 30% being tumors with dimensions between 3 and 5 cm. You can also see the absence of space replacement

Semelka et al. [19], following a study carried out over a 2-year period, regarding the ampullary carcinoma, have concluded that the dimensions of this type of

of malignancies of the pancreatic-duodenal region [1] (**Figure 4**).

and dimensions of the ampullae should be analyzed.

gaps with diameters between 1–3, 3–5, and over 5 cm.

processes with dimensions over 5 cm.

neoplasia do not exceed 5.5 cm.

**88**

very small dimensions.

These are arguments in favor of the authors' assertions that vaterian carcinoma is largely the result of malignant transformation of an adenoma.

Also, the reduced size and the histopathological nature of the ampullary adenocarcinoma lead to the conclusion that this **type** of neoplasm is one with reduced aggressiveness.

The conventional radiological examination is excellently complemented by the computed tomographic exploration or by magnetic resonance that can detect space replacement processes with dimensions up to 1 cm. These are seen as small occurrences in the duodenal lumen, which cannot be detected by the standard radiological examination.

The report of detection of space replacement processes by the two associated methods, the examination of the duodenum in double-contrast and computed tomography or MRI, actually highlights a double number of processes of space replacement at the level of the ampulla of Vater, regardless of its size. Comparison of these two exploration techniques with each other, but also with endoscopic exploration, reveals a greater specificity of magnetic resonance exploration than computed tomographic exploration.

Semelka et al. [19], in a study on the reliability of radiological and imaging scanning techniques versus ERCP, concluded on the superior specificity of magnetic resonance scanning compared to computed tomography. At the same time, considering the potential risks of retrograde endoscopic cholangiopancreatography, it recommends MRI as the diagnostic method with the highest degree of specificity.

In conclusion, we have considered all the radio-imagistic methods of detecting the process of space replacement in the case of the vaterian ampullomas, which we presented at the beginning of this subchapter.

#### **3.3 The presence of the Frostberg sign**

The Frostberg sign, also known as the inverted "3" sign (**Figure 5**), represents, from a radiological point of view, a semiological contour modification, which translates into an enlargement of the duodenal papilla, in the center of which the insertion of the biliary and pancreatic ducts remains fixed.

From the etiological point of view, this radiological modification is nonspecific; it can be present both in the malignant tumors of the ampulla of Vater and in any enlargement of the head of the pancreas, whatever the cause.

#### **Figure 5.** *Frostberg sign.*

The existence of Frostberg's sign actually pleads for the secondary invasion of the ampullar "carrefour."

Radiologically the two convexities connected between them represent in fact the edges of the papilla, and the opacified spines between them correspond to filling the papillary orifice with contrast agent.

The existence of the Oddi sphincter, but at the same time the tumor infiltration, does not allow the reflux of the contrast agent neither in the duct of Wirsung nor in the main biliary duct.

The conventional treatises of conventional radiology place Frostberg's sign as the second in frequency in the radiological semiology of the vaterian ampulloma. At the same time, the specificity of this radiological manifestation is relatively small, recognizing that translating the enlargement of the papilla, in fact a papillary suffering, is incriminated, without being able to indicate its substrate.

Ferruci [20] considers the Frostberg sign to be a relatively rare sign, which has specificity with regard to the damage of the duodenal papilla, without being able to define the cause of this change.

The presence of the Frostberg sign in almost 60% of cases is detected in the vaterian ampullomas.

Although not pathognomonic, it is also found in pancreatic disorders; the Frostberg sign is frequently detected in ampullary carcinomas. With it we can differentiate, using the conventional radiological exploration only as a method of investigation, the vaterian ampulloma from the primitive duodenal malignancies. This assertion is based on the fact that any primitive malignant tumor, in which the developing area also includes the papilla, infiltrates the ampullae by erasing its outlines and damaging the specific architecture of the papillary folds.

Being a radiological contour modification, in the case of the double-contrast duodenum examinations, an exploration that achieves the maximum luminal distension is much better highlighted and thus reveals the finest modification of the duodenal contour.

#### **3.4 Rigidity**

In the case of ampullary adenocarcinomas, the segmental rigidity, from the level of the internal contour of the descending duodenum, above and/or underlying the tumor lesion, translates the neoplastic invasion by contiguity of the duodenal wall itself.

**91**

**Figure 6.**

*Vaterian ampulloma: Imprint.*

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

It is considered that the presence of rigidity on the internal contour of the descending duodenum is a radiological sign, which, associated with the lacuna, gives the radiological image a certain specificity regarding the vaterian ampulloma. Taking into account the pathophysiological substrate of rigidity and considering that the vaterian ampullomas are neoplasms with reduced aggression, a small percentage of only 20% is explained, so the duodenal invasion is present in less than

The presence of rigidity is considered important because it is one of the first signs that can be highlighted by the standard radiological examination, especially by the double-contrast probe duodenography, the method that achieves the most reliable distension of the duodenal lumen. Highlighting a segment that presents rigidity, including the duodenal papilla, may be useful in associating the Frostberg sign. In this case, a radiological differential diagnosis can be made between the vaterian ampulloma and papillary disorders of other etiologies. The presence of rigidity in the absence of the Frostberg sign reduces the probability of the existence of a vaterian ampulloma, but it cannot completely exclude this diagnostic possibility. At the opposite pole is the hypotonic duodenography, which, due to the lack of duodenal functional information, highlights the rigidity with more difficulty. From a dimensional point of view, the rigidity in the case it exists within the

Ferruci [20] considers the imprint an important sign of conventional radiological exploration in detecting a space replacement process located in the vicinity of

Although it is an intrinsic neoplastic process, the vaterian ampulloma may induce imprinting due to the accompanying pancreatic reaction or, another explanation would be that the vaterian ampulloma invaded the pancreas. Regardless of the nature of the cause in the situation of the vaterian adenocarcinoma, the impression is the result of the dimensional increase at the level of the head of the pancreas. In the case of the vaterian ampullomas, the imprint is found in up to 20%

The vaterian neoplasm is not a type of malignancy of the duodenum, but is localized within the duodenum, the vaterian ampulla being not a neighboring

the duodenum, without necessarily having the meaning of a neoplasm.

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

vaterian ampulloma has dimensions between 3 and 5 cm.

a quarter of cases [1].

**3.5 The imprint**

of cases.

organ.

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

It is considered that the presence of rigidity on the internal contour of the descending duodenum is a radiological sign, which, associated with the lacuna, gives the radiological image a certain specificity regarding the vaterian ampulloma.

Taking into account the pathophysiological substrate of rigidity and considering that the vaterian ampullomas are neoplasms with reduced aggression, a small percentage of only 20% is explained, so the duodenal invasion is present in less than a quarter of cases [1].

The presence of rigidity is considered important because it is one of the first signs that can be highlighted by the standard radiological examination, especially by the double-contrast probe duodenography, the method that achieves the most reliable distension of the duodenal lumen. Highlighting a segment that presents rigidity, including the duodenal papilla, may be useful in associating the Frostberg sign. In this case, a radiological differential diagnosis can be made between the vaterian ampulloma and papillary disorders of other etiologies. The presence of rigidity in the absence of the Frostberg sign reduces the probability of the existence of a vaterian ampulloma, but it cannot completely exclude this diagnostic possibility. At the opposite pole is the hypotonic duodenography, which, due to the lack of duodenal functional information, highlights the rigidity with more difficulty.

From a dimensional point of view, the rigidity in the case it exists within the vaterian ampulloma has dimensions between 3 and 5 cm.

#### **3.5 The imprint**

*Gastrointestinal Stomas*

the ampullar "carrefour."

**Figure 5.** *Frostberg sign.*

the main biliary duct.

vaterian ampullomas.

duodenal contour.

**3.4 Rigidity**

define the cause of this change.

the papillary orifice with contrast agent.

The existence of Frostberg's sign actually pleads for the secondary invasion of

Radiologically the two convexities connected between them represent in fact the edges of the papilla, and the opacified spines between them correspond to filling

The existence of the Oddi sphincter, but at the same time the tumor infiltration, does not allow the reflux of the contrast agent neither in the duct of Wirsung nor in

The conventional treatises of conventional radiology place Frostberg's sign as the second in frequency in the radiological semiology of the vaterian ampulloma. At the same time, the specificity of this radiological manifestation is relatively small, recognizing that translating the enlargement of the papilla, in fact a papillary suf-

Ferruci [20] considers the Frostberg sign to be a relatively rare sign, which has specificity with regard to the damage of the duodenal papilla, without being able to

The presence of the Frostberg sign in almost 60% of cases is detected in the

Although not pathognomonic, it is also found in pancreatic disorders; the Frostberg sign is frequently detected in ampullary carcinomas. With it we can differentiate, using the conventional radiological exploration only as a method of investigation, the vaterian ampulloma from the primitive duodenal malignancies. This assertion is based on the fact that any primitive malignant tumor, in which the developing area also includes the papilla, infiltrates the ampullae by erasing its

Being a radiological contour modification, in the case of the double-contrast duodenum examinations, an exploration that achieves the maximum luminal distension is much better highlighted and thus reveals the finest modification of the

In the case of ampullary adenocarcinomas, the segmental rigidity, from the level of the internal contour of the descending duodenum, above and/or underlying the tumor lesion, translates the neoplastic invasion by contiguity of the duodenal wall itself.

fering, is incriminated, without being able to indicate its substrate.

outlines and damaging the specific architecture of the papillary folds.

**90**

Ferruci [20] considers the imprint an important sign of conventional radiological exploration in detecting a space replacement process located in the vicinity of the duodenum, without necessarily having the meaning of a neoplasm.

Although it is an intrinsic neoplastic process, the vaterian ampulloma may induce imprinting due to the accompanying pancreatic reaction or, another explanation would be that the vaterian ampulloma invaded the pancreas. Regardless of the nature of the cause in the situation of the vaterian adenocarcinoma, the impression is the result of the dimensional increase at the level of the head of the pancreas.

In the case of the vaterian ampullomas, the imprint is found in up to 20% of cases.

The vaterian neoplasm is not a type of malignancy of the duodenum, but is localized within the duodenum, the vaterian ampulla being not a neighboring organ.

**Figure 6.** *Vaterian ampulloma: Imprint.*

The imprint may occur due to the segmental enlargement of the head of the pancreas, due to the perilesional edema.

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 folds (**Figure 6**).

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 level of the descending duodenum.
