Pyogenic granuloma of the common bile duct in a patient with choledochoduodenostomy

Pyogenic granuloma is a polypoid form of capillary hemangioma that occurs mostly on the skin and the mucous membranes of the nasal and oral cavities [1]. Although pyogenic granuloma in the digestive tract excluding the oral cavity is a rarity, it can cause significant gastrointestinal bleeding, and curative resection is required for treatment in most cases [2]. We describe a case of pyogenic granuloma of the common bile duct (CBD) that was observed on endoscopy and was successfully treated by endoscopic snare polypectomy.

A 69-year-old woman was admitted to our hospital with a 1-day history of right upper quadrant pain. She had a history of cholecystectomy and CBD exploration with side-to-side choledochoduodenostomy and recurrent attacks of cholangitis. On endoscopic retrograde cholangiography (ERC) using an Olympus duodenoscope (JF-240; Olympus Optical Co., Tokyo, Japan), the CBD was cannulated with a balloon catheter through the wide stoma of the side-to-side choledochoduodenostomy ([Fig. 1] a) and the CBD visualized. A nonmovable, small, round filling defect was noted in the dilated distal CBD ([Fig. 1] b). Because of the wide stoma of the choledochoduodenostomy and the dilated CBD, it was possible to insert a forward-viewing endoscope (Olympus GIF-Q260; Olympus Optical Co.) through the stoma into the distal CBD. This showed a semipedunculated, smooth polypoid lesion that was 5 mm in diameter, hyperemic, and dark red in the distal CBD, with a tinge of blood on its surface ([Fig. 2] a). The lesion was removed by snare polypectomy without any complications ([Fig. 2] b). On the basis of histopathological analysis of the resected tissue ([Fig. 3]), the lesion was diagnosed as a pyogenic granuloma. To the best of our knowledge, this is the first reported case of pyogenic granuloma in the bile duct.

Fig. 1 a Duodenoscopic findings of a wide stoma in the side-to-side choledochoduodenostomy in the duodenum (arrow). b Endoscopic retrograde cholangiogram showing dilated distal common bile duct with a nonmovable, small, round filling defect (arrow).

Fig. 2 a Endoscopic view of the polypoid lesion in the distal common bile duct. b No residual lesion in the distal common bile duct after endoscopic snare polypectomy.

Fig. 3 a Histological section of the resected specimen showing proliferation of small capillary-sized blood vessels and surface ulceration, accompanied by lymphocytic infiltration in the intervening stroma (hematoxylin and eosin, original magnification, × 200). b Immunohistochemical staining for CD31 shows strong positivity in endothelial cells lining the small blood vessels (original magnification, × 400).

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References

• 1 Lin R L, Janniger C K. Pyogenic granuloma.  Cutis. 2004;  74 229-233
• 2 Kusakabe A, Kato H, Hayashi K. et al . Pyogenic granuloma of the stomach successfully treated by endoscopic resection after transarterial embolization of the feeding artery.  J Gastroenterol. 2005;  40 530-535