P0091 - Metastatic Melanoma Masquerading in the Ampulla of Vater: A Rare Encounter of Obstructive Jaundice

Het Patel, DO¹, Frank Lin, DO², Pooja Patel, DO³, Ying Lu, MD³, Noel Martins, MD³, Manoj Mittal, MD^3
1St. Luke's University Health Network, Bethlehem, PA; ²St. Luke's University Health Network, Easton, PA; ³St. Luke's University Health Network, Bethlehem, PA

Introduction: Malignant melanomas are aggressive cancers, typically metastasizing to the lymph nodes, lungs, and liver; however, they may also metastasize to gastrointestinal tract. We report a rare case of metastatic melanoma involving the Ampulla of Vater presenting as obstructive jaundice.

Case Description/Methods: A 76-year-old female presented to the hospital with several weeks of right upper quadrant abdominal pain radiating to the back with associated bloating, belching, early satiety, decreased appetite, beige colored stools and 12 pound unintentional weight loss over one and a half months. Pertinent history was significant for melanoma of the right arm diagnosed 16 years ago. Labs revealed AST 309U/L, ALT 449U/L, alkaline phosphatase 1,022 U/L, total bilirubin 2.2mg/dL, and lipase 418U/L. CT of the abdomen and pelvis revealed bi-lobar intrahepatic biliary ductal dilatation, a 1.7cm liver lesion, and an atrophic pancreas with pancreatic head fullness and soft tissue adjacent to the SMA and portosystemic confluence concerning a pancreatic or ampullary mass. CA 19-9 level was unremarkable. MRI/MRCP showed a large 7.1 x 6.2 x 7.1 cm pancreatic head mass with dilation of the main pancreatic duct, intrahepatic, and extrahepatic ducts consistent with malignancy along with multiple hepatic metastases. She subsequently underwent ERCP revealing a large ampullary mass with biopsies immunopositive for S100 and Sox10, confirming a diagnosis of metastatic melanoma. Two attempts for stent placement via ERCP were unsuccessful due to the obstruction. She ultimately underwent fluoroscopy-guided recanalization of the occluded distal common bile duct followed by percutaneous biliary drain placement with successful relief of the obstruction. She was initially started on chemotherapy but expired two months later due to critical limb ischemia secondary to acute aortic occlusion in the setting of her malignancy.

Discussion: In the case of AV obstruction, an endoscopic palliative stent can be placed to relieve the obstruction. We, however, found a percutaneous approach equally effective when the obstruction limits endoscopic intervention. Gastrointestinal manifestations of metastatic melanoma are not uncommon and therefore ampullary metastasis should be part of the differential in all patients presenting with obstructive jaundice with a history of malignant melanoma.



Disclosures:


Het Patel, DO¹, Frank Lin, DO², Pooja Patel, DO³, Ying Lu, MD³, Noel Martins, MD³, Manoj Mittal, MD³. P0091 - Metastatic Melanoma Masquerading in the Ampulla of Vater: A Rare Encounter of Obstructive Jaundice, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.