Background: 32-year-old young male presented with fever, jaundice, pruritus with significant weight loss and loss of appetite.

Diagnosis and treatment: On side viewing endoscopy, large mass lesion seen infiltrating the ampulla and periampullary region was seen. Biopsy from mass lesion revealed poorly differentiated adenocarcinoma. In view of cholangitis, biliary drainage by ERCP (Endoscopic Retrograde Cholangiopancreatography) was tried. However, biliary access was not feasible because of duodenal luminal narrowing and diffuse infiltration. Subsequently, EUS (Endosonography) guided choledochoduodenostomy from first part of duodenum was done and fully covered biliary  metallic stent was placed. The procedure was uneventful and patient fever and jaundice subsided. On follow up visit, bilirubin was in normal range, and the patient was planned for chemoradiation due to locally advanced tumor.