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Tubular adenoma arising in a choledochocele

      A 64-year-old woman was admitted to our hospital because of high amylase levels. Contrast-enhanced CT revealed dilatation of the distal common bile duct in the wall of the duodenum at the oral side of the ampulla of Vater and a 10-mm nodule with contrast medium enhancement in the dilatated common bile duct. Duodenoscopy revealed an elevated lesion above the ampulla of Vater (Fig. 1A). Additionally, ERCP showed a cystic dilatation at the oral side of the ampulla of Vater and a 10-mm filling defect in the cystic dilatation (Fig. 1B). Moreover, intraductal US showed an anechogenic cystic mass with an echogenic nodule. On the basis of these findings, the patient was considered to have a choledochocele with a nodule. For diagnosis of the nodule, an incision was made in the roof of the choledochocele with a needle-knife, and a direct biopsy of the nodule on the inner surface of the choledochocele was performed (Fig. 1C). Histologic examination of the biopsy specimen indicated a tubular adenoma (Fig. 1D). The final diagnosis was tubular adenoma arising in a choledochocele, and the patient underwent a pylorus-preserving pancreaticoduodenectomy. This is a rare case of a choledochocele associated with a tubular adenoma, and we demonstrate the method of direct biopsy of a nodule in a choledochocele for diagnosis (Video 1, available online at www.giejournal.org).
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      Figure 1A, Duodenoscopic view showing an elevated lesion above the ampulla of Vater. B, ERCP view showing a cystic dilatation at the oral side of the ampulla of Vater and a 10-mm filling defect in the cystic dilatation. C, Needle-knife incision is made in the roof of the choledochocele. D, Tubular adenoma identified by histologic analysis (left, H&E, orig. mag. ×40; right, H&E, orig. mag. ×200).
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