A 60-year-old patient presents with pruritus and obstructive jaundice. Physical examination reveals a palpable, non-tender gallbladder. What is the most likely diagnosis?

1. A

   Choledocholithiasis

2. B

   Carcinoma of the head of the pancreas

3. C

   Cholangiocarcinoma

4. D

   Gallbladder carcinoma

Appeared in: AIIMS Manglagiri NO - 2019

Explanation

• The patient's signs and symptoms (obstructive jaundice with a palpable, non-tender gallbladder) constitute Courvoisier's sign.
• Courvoisier's law posits that this presentation is typically caused by a malignant obstruction of the common bile duct, not by gallstones.
• Carcinoma of the head of the pancreas is the most common cause of extrinsic compression of the distal common bile duct, leading to the gradual, painless distension of the gallbladder.

Why Other Options Were Wrong

• Option A: According to Courvoisier's law, obstruction due to gallstones (choledocholithiasis) is associated with a chronically inflamed, fibrotic, and non-distensible gallbladder, which would not be palpable.
• Option C: While cholangiocarcinoma (bile duct cancer) can cause obstructive jaundice, it is a less frequent cause of the classic Courvoisier's sign compared to pancreatic head cancer.
• Option D: Cancer originating in the gallbladder is more likely to present as a fixed, hard, and potentially tender mass due to direct infiltration and inflammation, rather than a smoothly enlarged, non-tender gallbladder.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Differential diagnosis of obstructive jaundice and the clinical application of Courvoisier's Law to guide bedside assessment, documentation, and the next nursing action.
• Recognizing Courvoisier's sign is critical for nurses as it is a major red flag for a serious underlying malignancy, often pancreatic cancer.
• Nursing care for such patients involves managing severe pruritus (itching) with medications like cholestyramine, monitoring for signs of bleeding due to vitamin K malabsorption, and providing psychological support due to the poor prognosis associated with the likely diagnosis.
• What if? If the patient had presented with fever, chills, and a tender right upper quadrant, the diagnosis would shift towards acute cholangitis, likely secondary to choledocholithiasis, and would be a medical emergency requiring immediate antibiotics and biliary drainage.

How to Approach the Question

• First, identify the key clinical findings in the patient vignette: obstructive jaundice (pruritus, jaundice) and a palpable, non-tender gallbladder.
• Recognize this specific combination of signs as a classic, named clinical sign: Courvoisier's sign.
• Recall the principle of Courvoisier's law: it differentiates between malignant obstruction (palpable gallbladder) and gallstone obstruction (non-palpable gallbladder).
• Evaluate the options based on this law. Carcinoma of the head of the pancreas is the textbook cause of malignant obstruction leading to Courvoisier's sign.
• Eliminate choledocholithiasis because it violates the principle of the law.
• Consider the other malignancies (cholangiocarcinoma, gallbladder carcinoma) but recognize that pancreatic head cancer is the most common and classic cause for this presentation.

Concept Tested & Keywords

• Concept Tested: Differential diagnosis of obstructive jaundice and the clinical application of Courvoisier's Law.
• Stem keywords: obstructive jaundice, pruritus, palpable gallbladder, non-tender gallbladder
• Lead-in keywords: most likely diagnosis
• Clinical cues: The combination of painless jaundice and a palpable, non-tender gallbladder is a classic sign known as Courvoisier's sign, which strongly suggests a malignant obstruction.

Question ID

QuAw9OoiKmvP13RQFXGzLn

Copy ID

Reference Book

E6 Medicine Harrison 22e Part 2 pp. 639-641, 641-643