Small intestine & ampulla



Editor-in-Chief: Debra L. Zynger, M.D.
Raul S. Gonzalez, M.D.

Topic Completed: 10 December 2020

Minor changes: 2 June 2021

Copyright: 2002-2021,, Inc.

PubMed Search: Ampulla of vater [title] normal histology

Raul S. Gonzalez, M.D.
Page views in 2020: 5,856
Page views in 2021 to date: 6,129
Cite this page: Gonzalez RS. Histology-ampulla. website. Accessed December 7th, 2021.
Definition / general
  • Formed by the union of the distal pancreatic duct and the intrapancreatic distal common bile duct
  • Opens into the major duodenal papilla
Essential features
  • Complex anatomical structure generally lined by pancreatobiliary-type cells
Diagrams / tables

Images hosted on other servers:
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Ampulla of Vater and related structures

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Ampulla, papilla and sphincters

Microscopic (histologic) description
  • Ampullary mucosa forms prominent papillary folds
  • Epithelium transitions from intestinal type (duodenal surface) to foveolar-like mucosa with occasional goblet cells (papilla) to pancreatobiliary epithelium (distal ducts) (Am J Surg Pathol 2012;36:1592)
  • Lamina propria has only occasional lymphocytes, plasma cells and mast cells
  • Small mucous glands / ductules underlie the mucosa
  • Smooth muscle fibers (representing sphincter of Oddi) may extend into epithelial folds
  • May have adjacent pancreatic acini, but usually no islets around major papillae
Microscopic (histologic) images

Contributed by Raul Gonzalez, M.D.
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Normal ampullary mucosa and submucosa

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Ampullary submucosal glands / ductules

Positive stains (IHC and special stains)
  • Ampullary biopsy performed in autoimmune pancreatitis can help to differentiate from other "mass forming" pancreatitis by IgG4+ to IgG+ ratio (Am J Surg Pathol 2008;32:1770)
Differential diagnosis
  • Adenocarcinoma: submucosal ducts / glands may appear malignant, especially if crushed or secondarily involved by an adenoma
Board review style question #1
    Which of the following may be seen or around in normal ampullary mucosa?

  1. Ciliated epithelium
  2. Islets of Langerhans
  3. Pancreatic acini
  4. Squamous epithelium
Board review style answer #1
C. Pancreatic acini

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Reference: Histology-ampulla
Board review style question #2

    A patient with a bile duct stricture undergoes esophagogastroduodenoscopy. A biopsy is taken of the ampulla and is shown above. What is the correct diagnosis for this sample?

  1. Adenocarcinoma
  2. Gastric heterotopic
  3. Intestinal metaplasia
  4. Normal ampulla
Board review style answer #2
D. Normal ampulla

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Reference: Histology-ampulla
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