A 76-year-old male liver-transplant recipient (HBV-associated cirrhosis with prior HCC, transplanted 1998) initially presented for routine check-up without complaints. Shortly afterwards, he developed a superficial leg vein thrombosis and was started on rivaroxaban by his GP. Three weeks later, he returned with weakness and melaena to our hospital. Laboratory tests revealed severe anaemia (haemoglobin 6.5 g/dL) with otherwise stable liver and renal parameters. Emergency gastroscopy showed active periampullary bleeding with clot and a suspected subepithelial mass. A side-view examination was attempted but adequate visualization was impossible due to persistent bleeding. CT angiography demonstrated active extravasation from the gastroduodenal artery and a 2.9-cm duodenal mass. Selective angiography confirmed bleeding from the pancreaticoduodenal arcade, which was temporarily controlled by embolization.

Subsequent ERCP excluded papillary bleeding but revealed an infiltrative periampullary lesion. Histology confirmed moderately differentiated duodenal adenocarcinoma. Staging showed no metastases, and surgery was planned. In March, exploratory laparoscopy demonstrated tumour infiltration of the mesenteric root, rendering resection unfeasible. Palliative treatment was initiated.

Following surgery, galliferous wound drainage and cholangitis developed, accompanied by multiple enterocutaneous fistulas requiring continuous wound-bag management. Progressive distal bile duct obstruction prompted repeated ERCPs with metal-stent placement and extensive lavage. Due to pronounced intra- and extrahepatic cholestasis with severe cholangitis, an emergency CT-guided PTCD was placed in April 2025 but could not be internalized into the small intestine. Via subsequent ERCP a covered self-expandable metall stent was placed to allow for internal drainage.

The patient’s condition deteriorated with abdominal pain, weakness, and malnutrition. Planned palliative chemotherapy was cancelled owing to reduced performance status. He was transferred to the palliative care unit in June 2025 with ECOG 3–4 status, persistent fistulas, post-prandial pain, and general decline. Supportive care included nutritional support, analgesic optimization, antibiotics for recurrent cholangitis, wound and stoma care, physiotherapy, and psycho-oncology. Gradual stabilization allowed discharge to a hospice care in July 2025, where he passed shortly thereafter.

This case underscores the complexity of managing periampullary malignancy in transplant recipients, requiring tightly coordinated multimodal and palliative care.