Victoria Gomez, MD and Lady Katherine Mejia Perez, MD from the Department of Gastroenterology and Hepatology at the Mayo Clinic, Jacksonville, Florida present this video case.

We describe the case of a 65-year-old man who was diagnosed with follicular lymphoma of the ampulla of Vater. He underwent an EGD for evaluation of long-standing symptoms of GERD. Upon slow withdrawal of the forward-viewing endoscope within the duodenum, a mucosal abnormality was incidentally noticed. It was further evaluated with duodenoscopy and linear array EUS, demonstrating an 18-mm whitish mucosal lesion distorting the major papilla. Immunohistochemistry was diagnostic of follicular lymphoma.  PET scan and abdominal MRI showed no lymph node involvement, confirming primary gastrointestinal disease. The patient was treated with 5 courses of Rituximab, and on surveillance endoscopy after treatment completion, resolution of the lesion was confirmed.

This case demonstrates a rare asymptomatic condition, which was diagnosed after careful examination of the major papilla during a routine upper endoscopy. Often times during routine upper endoscopy, the major papilla is overlooked due its challenging position. After recognition of the abnormal papilla seen on endoscopy, a prompt diagnosis was made and allowed for successful nonsurgical treatment. Although the management of this condition is highly heterogeneous in the literature, collaboration with hemato-oncology resulted in a successful treatment.

During routine upper endoscopy (or for any indication for that matter), endoscopists should always perform a slow withdrawal of the endoscope in order to carefully examine the major papilla. Asymptomatic lesions can be easily missed. Endoscopists should have a consistent and standardized method for examining the foregut on any endoscopy to ensure a high-quality examination.

Figure 1. A, Whitish nodular lesion of the ampulla detected on upper endoscopic evaluation.B, Linear array EUS view, showing 18-mm polypoid lesion involving the major papilla, confined to the mucosa.C, Pathologic specimen stained with H&E, showing neoplastic follicles in the duodenal lamina propria and submucosa (blue arrow; H & E, orig. mag. 10). D, Repeated upper endoscopy with duodenoscope after chemotherapy, showing completeresolution of the lesion.

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