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