Endgames Picture Quiz

Obstructive jaundice and pancreatic disease

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6701 (Published 15 October 2012) Cite this as: BMJ 2012;345:e6701
  1. Sunita Deshmukh, academic clinical trainee,
  2. Keith Roberts, specialty registrar, hepatobiliary surgery,
  3. Andrew M Smith, consultant, hepatobiliary surgery
  1. 1St James’s University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
  1. Correspondence to: A M Smith andrewmalvernsmith{at}me.com

A 72 year old man was admitted under the surgical team with a short history of upper abdominal pain associated with vomiting, pruritis, pale stools, and dark urine. Four days earlier he had presented to his general practitioner with a four week history of polydipsia and polyuria. His fasting blood glucose concentration was raised. He was clinically diagnosed with new onset type 2 diabetes and given dietary advice. He drank alcohol occasionally and was a smoker with a history of chronic obstructive pulmonary disease and cystectomy for transitional cell carcinoma of the bladder 10 years previously.

On examination he was haemodynamically stable, jaundiced, and had a normal temperature. His abdomen was soft and non-tender with no palpable masses. Liver function tests were abnormal: alanine aminotransferase 783 U/L (reference range 3-35), bilirubin 76 μmol/L (3-17; 1 μmol/L=0.06 mg/dL), and alkaline phosphatase 911 U/L (30-35). His C reactive protein was 111 nmol/L (reference value <100; 1 nmol/L=0.1 mg/L) and serum amylase was normal. With the exception of hyperglycaemia, routine blood tests were normal. He was started on an insulin sliding scale with fluid replacement.

Ultrasonography showed intrahepatic and extrahepatic biliary dilation, although no cause was identified. No obstructing or mass lesion was seen on computed tomography of the abdomen (fig 1). The cross sectional images helped confirm the diagnosis and were supported by a serum test.

Fig 1 Computed tomogram of the abdomen (cross sectional view)


  • 1 What abnormality can be seen in fig 1 and what is the likely diagnosis given these findings and the history?

  • 2 What are the main differential diagnoses?

  • 3 How would you manage this patient?


1 What abnormality can be seen in fig 1 and what is the likely diagnosis given these findings and the history?

Short answer

Figure 1 shows a diffusely swollen pancreas with loss of normal gland lobulation. Dilation of the common bile duct is present but no mass lesion. The likely diagnosis is …

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