Pruritus as the First Clue: Early Diagnostic Workup Uncovering an Ampullary Adenoma

Ampullary adenomas are uncommon lesions with malignant potential and may present with nonspecific symptoms, making diagnosis challenging. This is the case of a 64-year-old woman who presented with diffuse pruritus, right upper quadrant discomfort, and a cholestatic liver pattern injury, posteriorly found to have an ampullary lesion causing biliary obstruction. Initial endoscopic evaluation and biopsy suggested low-grade dysplasia, with temporary improvement after biliary decompression. However, persistent symptoms prompted repeat intervention with endoscopic papillectomy, and final pathology demonstrated high-grade dysplasia with positive margins, raising concern for an underlying malignancy not identified on the initial biopsy. This case highlights the variable clinical presentation of ampullary adenomas and emphasizes the limitations of superficial tissue sampling, underscoring the importance of complete histologic evaluation and close follow-up in suspicious ampullary lesions.