Common Bile Duct Elongation and Obstruction Secondary to Duodenal Intussusception and Ampullary Adenoma in a Patient with Pancreas Divisum

Introduction

Small bowel intussusception is an uncommon condition with cases of duodenoduodenal intussusception. (DDI) being exceptionally rare. DDI is very unusual due to the fixed position of the duodenum within the retroperitoneum. In this case, the presence of an ampullary mass caused DDI with sub mucosal elongation of the common bile duct and obstructive jaundice in a patient with pancreas divisum.

Methods

65-year-old female who underwent ERCP for Jaundice, abnormal liver function test, acquired bile duct dilation and Cholangitis like symptoms. She was found to have ampullary mass causing intussusception and Pancreas Divisum (Figure 1).

The large tumor was identified in the third part of the duodenum. CT scan and MRI revealed that there is an intussusception, with the elongated common bile duct entering the duodenum to the left of the midline (Figure 2).

Results

The tumor was palpated close to the Ligament of Treitz at exploration. The patient underwent Exploratory laparotomy, cholecystectomy, exploration of common bile duct, excision of ampulla of Vater with reimplantation of common bile duct. Due to the presence of Pancreas Divisum, no pancreatic duct was encountered within the ampulla, which was advantageous (Figure 3).

Conclusion

This is to our knowledge the first description of a duodenal intususception causing an elongation of the bile duct to the left of the midline.