Obstructive jaundice caused by an adenoma of the common hepatic duct

The main causes of obstruction of the bile duct are lithiasis and cancer. Benign tumours are much less common in this location and include simple polyps, adenomas and papillomas.¹ They can appear as isolated cases or associated with hereditary polyposis syndromes (familial adenomatous polyposis, Gardner syndrome or Peutz–Jeghers syndrome).²

We present the case of a 70-year-old man under follow-up for ulcerative pancolitis in whom a cholestasis pattern was detected in a routine analysis. Initially, magnetic resonance cholangiopancreatography showed dilation of the bile duct, which was abruptly cut off at the common hepatic duct, with signs of occupation of the lumen suggestive of neoformation. These findings were confirmed by computed tomography (CT). Endoscopic ultrasound was not performed because of the difficulty of accessing the technique in our centre.

Subsequently, endoscopic retrograde cholangiopancreatography (ERCP) was performed with cholangioscopy (SpyGlass), which identified dilation of the common hepatic duct and the left and right hepatic ducts, and a mobile filling defect in the common hepatic duct (Fig. 1). The cholangioscope showed a 10 mm polypoid lesion which was biopsied (with SpyBite forceps). The pathology report was of a papillary adenomatous polyp with moderate dysplasia.

Figure 1.

Adenoma of the bile duct.

After these findings, the patient was referred to the Hepatobiliary Surgery Department and subsequently had bile duct resection, cholecystectomy and hepaticojejunostomy, with good postoperative outcome. Analysis of the surgical sample confirmed the diagnosis of adenomatous polyp with moderate dysplasia.

Adenomas of the bile duct are rare,³ but are usually located in the distal common bile duct, close to the duodenal papilla.⁴ According to the WHO (World Health Organisation), they can be classified as tubular, papillary, tubulopapillary, cystadenomas or papillomatosis.² They are more common in people in their fifties and are usually symptomatic, causing jaundice, abdominal pain, weight loss, nausea, vomiting and pyrexia.⁴

We have presented the case of this patient because of the uncommon location of a papillary adenoma in the common hepatic duct, having found only isolated cases involving the common bile duct in the literature.⁵

Our case also shows the utility of cholangioscopy for taking biopsies in order to correctly diagnose this type of lesion which, using other imaging tests (CT/MRI), could be confused with a malignant neoformation¹ and lead us to mistakenly opt for more aggressive surgical interventions.