Ectopic location of the ampulla of vater within the pyloric channel

The ampulla of Vater is commonly located in the posteromedial wall of the second portion of the duodenum. At times, the ampulla of Vater may be found at uncommon sites such as the third and fourth portions of the duodenum, the duodenal bulb and the stomach. We found the ampulla of Vater in the pyloric channel in a 44 year old patient who had undergone surgery for acute cholecystitis. An intra-operative T-tube cholangiography revealed distal narrowing. The major papilla was not found during endoscopic retrograde cholangiopancreatography (ERCP) and a more accurate T-tube cholangiography revealed that the common bile duct opened in the distal stomach, probably in the pylorus. Finally the ampulla opening was located in the pylorus by methylene blue injection through the T-tube at endoscopy. This rather unusual location of the ampulla of Vater has implications for gastroenterologists performing ERCP.