Clinical Case: 65-Year-Old Male with Progressive Painless Jaundice — Cholangiocarcinoma

Version 1.0 — Published April 2026

The case

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.

History and examination

General examination:

• Deep icterus (scleral and skin jaundice)
• Scratch marks over the trunk and limbs (pruritus from bile salt deposition in skin)
• No palpable lymphadenopathy
• BMI: 21 kg/m2 (from 24 kg/m2 two months prior)

Abdominal examination:

• Abdomen: soft, non-tender
• Palpable gallbladder — smooth, non-tender, globular swelling in the right hypochondrium, moves with respiration, cannot get above it
• Liver: palpable 3 cm below the costal margin, smooth surface, firm consistency, non-tender
• No ascites, no splenomegaly

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.

Differential diagnosis

The differential for progressive painless obstructive jaundice in an elderly patient:

The triad of painless jaundice + positive Courvoisier sign + weight loss narrows the differential to periampullary malignancies. Imaging will determine the exact site and nature.

Investigations

Laboratory findings:

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.

Diagnosis

Distal cholangiocarcinoma — adenocarcinoma arising from the epithelium of the distal common bile duct.

The diagnosis is supported by:

1. Progressive painless obstructive jaundice in an elderly patient
2. Positive Courvoisier sign
3. Elevated CA 19-9 (380 U/mL)
4. CT/MRCP showing a distal CBD mass with upstream biliary dilatation
5. No evidence of pancreatic parenchymal mass (distinguishes from pancreatic head carcinoma)
6. No vascular invasion or distant metastasis (resectable disease)

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.

Management

Pre-operative optimization

1. Correction of coagulopathy: Vitamin K 10 mg IV for 3 days to correct PT/INR (bile salt malabsorption impairs fat-soluble vitamin absorption — vitamins A, D, E, K).
2. Biliary drainage (if needed): Pre-operative biliary stenting (ERCP with plastic stent or percutaneous transhepatic biliary drainage/PTBD) is considered if total bilirubin exceeds 15 mg/dL, cholangitis is present, or surgery is delayed. Routine pre-operative stenting is controversial — some evidence suggests it increases infectious complications without survival benefit (van der Gaag et al., NEJM 2010).
3. Nutritional optimization: High-calorie, high-protein diet. Pancreatic enzyme supplementation if steatorrhea is present. Correct hypoalbuminemia.

Definitive surgery: Whipple procedure

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):

1. Pancreaticojejunostomy — most dangerous; pancreatic fistula is the most feared complication
2. Hepaticojejunostomy — biliary reconstruction
3. Gastrojejunostomy — GI continuity

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.

Adjuvant therapy

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.

Unresectable disease

For unresectable or metastatic cholangiocarcinoma:

• Biliary stenting — ERCP with self-expanding metal stent (SEMS) for palliation of jaundice
• ABC-02 trial (Valle et al., NEJM 2010): Gemcitabine + cisplatin is the first-line palliative chemotherapy (median OS 11.7 months vs 8.1 months with gemcitabine alone)
• Palliative care — symptom management, nutritional support, pain control

NEET PG angle

NBE tests periampullary malignancies through:

1. Clinical vignettes — painless jaundice, Courvoisier sign, weight loss; identify the diagnosis
2. Investigation choice — MRCP for anatomy, CT for resectability, ERCP for stenting
3. Surgical procedure — Whipple for distal, hepatectomy for hilar, know the three anastomoses
4. Named signs — Courvoisier law (palpable gallbladder = malignant obstruction), double duct sign on imaging

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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.