NEET PG clinical case walkthrough: an elderly man presents with progressive painless jaundice, pruritus, and weight loss. Step-by-step diagnosis and management of cholangiocarcinoma with Courvoisier sign, MRCP findings, and practice MCQs.
Version 1.0 — Published April 2026
A 65-year-old retired farmer presents to the surgical OPD with progressive yellowing of the skin and eyes for the past 3 weeks. He reports intense itching that worsens at night and disturbs his sleep. His stools have become pale and clay-colored over the past 10 days, while his urine has turned dark brown. He has lost approximately 6 kg in the past 2 months without intentional dieting. He denies abdominal pain, fever, nausea, or vomiting.
He has no history of jaundice, liver disease, alcohol use, or blood transfusions. He takes amlodipine for hypertension and metformin for type 2 diabetes. No prior surgeries. No family history of malignancy.
The critical clue in this vignette: progressive painless obstructive jaundice with weight loss in an elderly patient — this presentation is malignant biliary obstruction until proven otherwise.
General examination:
Abdominal examination:
Courvoisier sign is positive: Jaundice with a palpable non-tender gallbladder. Courvoisier law states that this combination is unlikely to be caused by gallstones (chronic stone disease causes a fibrosed, non-distensible gallbladder). The positive Courvoisier sign points to malignant biliary obstruction — carcinoma of the head of pancreas, distal cholangiocarcinoma, or ampullary carcinoma.
The differential for progressive painless obstructive jaundice in an elderly patient:
| Diagnosis | Points in favor | Points against |
|---|---|---|
| Cholangiocarcinoma (distal) | Progressive painless jaundice, positive Courvoisier sign, weight loss, elderly male | Cannot distinguish from pancreatic head carcinoma clinically |
| Carcinoma head of pancreas | Same presentation as cholangiocarcinoma, positive Courvoisier sign | No back pain (common in pancreatic carcinoma), no new-onset diabetes in this case |
This content is for educational purposes for NEET PG exam preparation. It is not a substitute for professional medical advice, diagnosis, or treatment. Clinical information has been reviewed by qualified medical professionals.
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Join on Telegram →| Painless jaundice, Courvoisier sign |
| Often presents with intermittent jaundice (tumor necrosis causes temporary relief — "silver stool" with melena mixed with pale stool) |
| Choledocholithiasis | Common cause of obstructive jaundice | Typically painful (biliary colic), fever (cholangitis), gallbladder not distensible (Courvoisier negative) |
| Pancreatic head mass (other) | Obstructive jaundice | Includes lymphoma, metastasis — rare compared to adenocarcinoma |
| Primary sclerosing cholangitis | Stricturing of bile ducts, jaundice | Younger age, associated with ulcerative colitis, fluctuating jaundice |
The triad of painless jaundice + positive Courvoisier sign + weight loss narrows the differential to periampullary malignancies. Imaging will determine the exact site and nature.
Laboratory findings:
| Test | Result | Interpretation |
|---|---|---|
| Total bilirubin | 14.2 mg/dL (direct 11.8 mg/dL) | Conjugated (direct) hyperbilirubinemia — obstructive pattern |
| ALP | 620 U/L (normal <130) | Markedly elevated — hallmark of biliary obstruction |
| GGT | 480 U/L (normal <60) | Elevated — confirms biliary origin of elevated ALP |
| AST/ALT | 85/92 U/L | Mildly elevated (hepatocellular damage from back-pressure) |
| CA 19-9 | 380 U/mL (normal <37) | Elevated — supports malignant biliary obstruction |
| PT/INR | 16.2 s / 1.4 | Prolonged — Vitamin K malabsorption due to bile salt deficiency |
The pattern of markedly elevated ALP and GGT with mildly elevated transaminases is the classic obstructive jaundice biochemical profile.
Imaging:
Ultrasound abdomen: Dilated intrahepatic bile ducts (IHBD) and common bile duct (CBD) with an abrupt cutoff in the distal CBD. Distended gallbladder. No gallstones. An ill-defined hypoechoic mass at the distal CBD near the head of pancreas.
CT abdomen (triple-phase with contrast): 2.5 cm enhancing mass in the distal common bile duct causing upstream biliary dilatation. No vascular encasement (superior mesenteric vein, portal vein, and hepatic artery are clear). No liver metastases. No peritoneal disease. The pancreatic parenchyma appears normal — this helps distinguish distal cholangiocarcinoma from pancreatic head carcinoma.
MRCP: Confirms a focal stricture of the distal CBD with upstream dilatation of the entire biliary tree. The pancreatic duct is mildly dilated (double duct sign). No intrahepatic lesions. No hilar involvement — this is a distal cholangiocarcinoma, not a Klatskin tumor.
Distal cholangiocarcinoma — adenocarcinoma arising from the epithelium of the distal common bile duct.
The diagnosis is supported by:
Cholangiocarcinoma is the second most common primary hepatobiliary malignancy after hepatocellular carcinoma. Distal cholangiocarcinoma accounts for 20-30% of all cholangiocarcinomas. The overall incidence is 1-2 per 100,000 population, with higher rates in Southeast Asia due to liver fluke infection (Clonorchis sinensis, Opisthorchis viverrini). In India, most cases are sporadic.
For resectable distal cholangiocarcinoma, pancreaticoduodenectomy (Whipple procedure) is the standard curative operation.
Structures resected: Head of pancreas, entire duodenum, distal common bile duct (including the tumor), gallbladder, and the antrum of the stomach (in classic Whipple; pylorus-preserving variant retains the stomach).
Three anastomoses (proximal to distal):
Surgical margins: R0 resection (negative microscopic margins) is the single most important prognostic factor. R1 (microscopic residual disease) and R2 (macroscopic residual) have significantly worse outcomes.
BILCAP trial (Primrose et al., Lancet Oncology 2019): Capecitabine for 6 months after R0/R1 resection significantly improved overall survival in biliary tract cancers (median OS 51.1 months vs 36.4 months). This established adjuvant capecitabine as the standard of care.
For unresectable or metastatic cholangiocarcinoma:
NBE tests periampullary malignancies through:
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This content is for educational purposes for NEET PG exam preparation. It is not a substitute for professional medical advice, diagnosis, or treatment. Clinical information has been reviewed by qualified medical professionals.
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Written by: NEETPGAI Editorial Team Reviewed by: NEETPGAI Medical Advisory Board Last reviewed: April 2026
This article is reviewed by qualified medical professionals for clinical accuracy and exam relevance. For corrections or updates, contact the editorial team.