A 52 year old man was referred to the jaundice hotline clinic by his general practitioner with symptoms of malaise and lethargy over one year and a seven day history of jaundice. Apart from a laparoscopic cholecystectomy eight years earlier, he had no other relevant medical history and took no drugs. On examination, he was jaundiced but had no other abnormal physical signs.

His laboratory findings were: bilirubin 135 µmol/l (normal range 3-17), alkaline phosphatase 971 U/l (3-110), alanine aminotransferase 154 U/l (3-35), albumin 35 g/l (35-45).

Ultrasound of the liver showed coarse echotexture and no intrahepatic biliary duct dilatation. Views of the common bile duct were poor owing to overlying bowel gas.

The patient went on to have endoscopic retrograde cholangiopancreatography as an outpatient (fig 1⇓).