A 50 year old man presents with jaundice and itching for 2 weeks. There was no history of fever, abdominal pain, loss of appetite, or loss of weight. His C-reactive protein (CRP) is 15 mg/L, while a full blood count, renal functions, and serum electrolytes are all within normal parameters.
Total bilirubin: 25 mg/dL (<1.2) Direct bilirubin: 10 mg/dL ALP: 580 U/L (35-104) GGT: 178 U/L (<39) ALT, AST, INR: within normal parameters
The intrahepatic bile ducts are dilated, although the common bile duct is normal in size. The gallbladder is collapsed. The liver parenchyma and pancreas appear normal.
MRCP shows an irregular stricture at the biliary confluence, with symmetric dilatation of intrahepatic tree. MRI shows a 2×3cm mass in the same area, with T1 hypointensity and T2 hyperintensity. An enlarged retro-pancreatic lymph node is noted.
The chest x-ray appears normal.