A Rare Ampullary Mass: Think Outside the Box

A 75-year-old lady presented with nausea/vomiting and right upper quadrant pain of 1-day duration, preceded by dizzy spells. She had prior history of coronary bypass a decade ago, and hypertension. She was hemodynamically stable and initial lab work, including complete blood count, kidney profile, amylase/lipase, and hepatic panel were unremarkable. Ultrasound suggested dilated common bile duct (CBD) and intrahepatic bile ducts. Computed tomography (CT) with pancreas protocol showed severe intra- and extra-hepatic biliary ductal dilation with a 1.1x0.5 cm mass near the ampulla, raising concerns for possible neoplastic process. She was unable to get magnetic resonance imaging (MRI) due to recent shoulder prosthesis. Endoscopic ultrasound (EUS) revealed a dilated (1.2 cm) CBD that tapered towards a bulbous ampulla, and confirmed an ampullary mass but no lymph nodes were detected (Figure A/B).