Synopsis
Recognise ampullary adenoma and carcinoma, obtain reliable histology and EUS-MRCP staging, select endoscopic papillectomy or pancreaticoduodenectomy, and monitor the papillectomy scar for recurrence.
- Ampullary tumours arise where the bile and pancreatic ducts meet the duodenum; even a small lesion can cause early jaundice, cholangitis or pancreatitis.
- Obtain side-viewing duodenoscopy with directed biopsies, recognising that superficial samples can miss deeper carcinoma and that discordant malignant features need repeat or definitive assessment.
- ESGE recommends both EUS and MRCP for staging ampullary tumours because depth, nodes and intraductal extension determine treatment.
Key red flags
Jaundice, weight loss, ulceration, firmness or spontaneous bleeding at the papilla raises invasive carcinoma and makes routine endoscopic excision unsafe without staging.
Biopsy-proven adenoma with more than 20 mm intraductal extension or a lesion larger than 4 cm may be technically unsuitable for papillectomy and requires surgical review.
Fever, rigors or hypotension with biliary dilatation requires urgent cholangitis treatment rather than waiting for elective tumour surveillance.
Severe epigastric pain, tachycardia, melaena, fever or peritonism after papillectomy needs urgent assessment for pancreatitis, bleeding, cholangitis or perforation.
Investigation priorities
Inspect papillary architecture and obtain histology before deciding on resection.
Management branches
Biopsies show ampullary adenoma; EUS finds no invasion or suspicious nodes and MRCP shows no intraductal extension.
- Review size, morphology, antithrombotic management and procedural fitness in an experienced therapeutic endoscopy service.
- Perform en-bloc endoscopic papillectomy when feasible and place a prophylactic pancreatic-duct stent according to ESGE guidance. For the selected stent intended for planned retrieval, book the six-week endoscopy now; symptoms suggesting obstruction require earlier review.