Ampullary Pyogenic Granuloma: Rare Cause of Iron Deficiency Anemia and Its Endoscopic Management

Introduction

A 35-year-old lady with a history of symptomatic iron deficiency anemia and positive fecal occult blood. Prior evaluation showed normal upper gastrointestinal (GI) endoscopy and ileocolonoscopy. Small bowel evaluation with computed tomography enterography and capsule endoscopy were normal. Patient was again evaluated at our center. Upper GI endoscopy showed erythematous lesion at the ampullary region. Side view endoscopy showed erythematous, polypoidal lesion at the ampulla with intermittent oozing of blood ([Fig. 1A]). With suspicion of ampullary malignancy, Endoscopic ultrasound was done, which showed hyperechoic, small lesion measuring less than 1 cm at the ampulla and not involving the deeper layers of the duodenum, bile duct, and pancreatic duct ([Fig. 1E]). Due to its superficial location, patient was taken for ampullectomy ([Fig. 1B]). Biopsy was not done prior to ampullectomy in view of small superficial lesion. Initially, gelofusine was instilled around the ampulla and using snare, hot snare ampullectomy was done. Specimen was retrieved with Roth Net. Ampullectomy base was clean with no bleeding. Prophylactic pancreatic duct stent (SPT 5Fr × 3cm) was placed to prevent pancreatitis ([Fig. 1C]). Histopathology of ampullectomy specimen showed congested and dilated capillaries with few inflammatory cells suggestive of pyogenic granuloma ([Fig. 1D]). Patient was monitored as inpatient for 3 days prior to discharge. After 2 weeks, patient remained asymptomatic with stable hemoglobin. Pancreatic duct stent was removed. Patient completed 4 months of follow-up with stable hemoglobin without any blood or intravenous iron transfusion.

Fig. 1 (A) Side view endoscopic view of the ampulla showing erythematous polypoidal lesion with fragile mucosa. (B) Resection of the ampulla with hot snare polypectomy. (C) Post-ampullectomy status and prophylactic pancreatic duct placement. (D) Histology of resected specimen: hematoxylin and eosin (H&E) staining, magnification view ×400 showing proliferation of capillaries lined with endothelial cells (marked as *) admixed with acute and chronic inflammatory cells (marked as #). (E) Endoscopic ultrasound image showing common bile duct (yellow arrow), pancreatic duct (white arrow), and small hypoechoic lesion in the periampullary region (orange arrow).

Pyogenic granuloma is a benign vascular proliferation usually seen in children and young adults on skin and mucous membranes. It rarely involves the GI tract and ampullary involvement is uncommon. Ampullary site of pyogenic granuloma is very rare and reported in only few case reports.[1] [2] [3]

Practical Implications for Endoscopists

• It is usually found in patients extensively evaluated for occult iron deficiency anemia.

• On endoscopy, importantly side view endoscopy, it is seen as protruding erythematous lesion involving the ampulla with fragile mucosa, which can bleed on touch.

• Definite diagnosis is based on histopathological examination and is characterized by lobular arrangement of proliferating capillaries. Other features include presence of chronic inflammatory cells, superficial stromal edema, capillary dilatation, and granulation tissue.

• Case reports showed complete response rates with resection with long-term follow-up and no recurrences were reported after resection. Pyogenic granuloma can be effectively treated by endoscopic resection (ampullectomy if it involves the ampulla).[2]

• Endoscopic evaluation of the ampulla, preferably with side view duodenoscope, should be considered in the evaluation of chronic GI bleed.

Conflict of Interest

None declared.

Note

The study was done at Institute of Gastroenterology, Hepatology and Endoscopy, Max Superspeciality Hospital, Saket, New Delhi, India.

Patient's Consent

The following case report is not a part of any research trial. Informed consent was taken from the patient for the publication of their information and imaging.

• References

• 1 Moreira Silva H, Silva G, Costa E, Lima R, Pereira F. Pyogenic granuloma of the ampulla of Vater: unexpected cause of gastrointestinal bleeding. Clin J Gastroenterol 2019; 12 (01) 34-37
• 2 Mandaliya R, Han S, Haddad N. Bleeding pyogenic granuloma of the ampulla of Vater: a rare cause of severe chronic anemia. Gastrointest Endosc 2019; 89 (05) 1066-1067
• 3 Meredith C, Albers GC, Lee JG. Ampullary pyogenic granuloma: 1880. American Journal of Gastroenterology 2017; 112: S1036

Publication History

Article published online:
22 May 2025