A plump ampulla

This patient presented with a raised ALP. A somewhat plump duodenal ampulla was the only visible abnormality. An abdominal ultrasound demonstrated an dilated CBD but a normal PD. A set of biopsies did not show any abnormalities. 
WHAT WOULD YOU DO NEXT?

■ ERCP

Contraindicated as the patient isn't jaundiced or septic!

■ MRI

'Tissue is the Issue'! And an MRI will not give you that!

■ EUS

YES! Because it will allow targeted biopsies of the mass which must be there!

explanation

The ampulla does indeed seem a little plump! There must be something inside it which is pushing it out like this!  We organised an EUS which confirmed a nodule inside the ampulla. FNA confirmed adenocarcinoma. As the lesion extended deeper than 5-6mm (on EUS) and because cancer was confirmed, there was no question about attempting an ampullectomy.  

As the patient was jaundiced and there was no suggestion of cholangitis, an ERCP would not be indicated.  A subsequent MRI also identified a small mass at the bottom end of the bile duct but of course could not provide the tissue diagnosis.