Impediment

A 63 year old man presents with worsening jaundice, steatorrhea, dark urine, pruritis and mild anorexia for 5 weeks. There was no malena or fever.

He gives a history of recurrent epigastric pain for many years, which was self medicated. His medical history is otherwise unremarkable. He only drinks a beer or two a week.

A full blood count was found to be normal.

Select Relevant Investigations
Liver function tests

Performed

AST: 70 IU/l (minimally elevated)
ALT: 76 IU/l (minimally elevated)
ALP: 800 IU/l (high)
Total Bilirubin: 8.1 mg/dl (high)
Direct Bilirubin: 5.6 mg/dl (high)
Ultrasound Abdomen

Performed

The ultrasound scan shows dilation of the intra-hepatic biliary ducts and the common bile duct. No gallstones are visualized. The liver parenchyma appears normal. The pancreatic parenchyma shows heterogeneous echogenicity.
CT Abdomen (contrast)

Performed

The CT scan shows an enlarged and irregular pancreas with calcifications, causing obstruction at the level of the distal common bile duct (CBD), with resultant extra and intra-hepatic biliary tract dilation.
Fasting Blood Glucose

Performed

His Fasting Blood Glucose is 88 mg/dl (normal).

Select Relevant Management
Pancreatin
Radiotherapy
Cholestyramine
Biliary Stenting