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?

Appeared in: INI-CET EXAM -2026

Explanation

The patient's signs and symptoms are a classic presentation of Courvoisier's law.
This law indicates that a palpable, non-tender gallbladder in a jaundiced patient is typically caused by a malignant obstruction of the bile duct, not gallstones.
Carcinoma of the head of the pancreas is the most frequent malignancy to cause this type of gradual, distal bile duct obstruction, leading to a distended gallbladder.
The obstruction is slow and progressive, which allows the gallbladder to enlarge without the inflammation that would cause tenderness.

Option A: Choledocholithiasis (gallstones in the common bile duct) typically arises from chronic cholecystitis. This condition causes the gallbladder to become fibrotic, scarred, and shrunken, so it cannot distend and is not palpable. If it were palpable due to acute inflammation, it would be tender.
Option C: Cholangiocarcinoma (cancer of the bile duct) can cause obstructive jaundice. However, for it to cause a palpable gallbladder, the tumor must be located distal to the entry of the cystic duct. While possible, carcinoma of the head of the pancreas is a more common cause of this specific clinical picture.
Option D: Gallbladder carcinoma originates within the gallbladder wall. It is more likely to present as a hard, irregular mass and may not cause the uniform, smooth distension seen in Courvoisier's sign. It often presents with symptoms similar to cholecystitis.

Clinical Relevance

Nursing practice connection: Use the key finding related to The clinical application of Courvoisier's law in diagnosing the cause of obstructive jaundice to guide bedside assessment, documentation, and the next nursing action.
Recognizing Courvoisier's sign (painless jaundice + palpable, non-tender gallbladder) is a critical physical assessment skill for nurses. It should prompt immediate suspicion of a serious underlying malignancy, most commonly pancreatic cancer.
Nurses should be prepared for subsequent diagnostic workups, including imaging (CT, MRI/MRCP) and endoscopic procedures (ERCP, EUS), and provide appropriate patient education and support.
Nursing care for patients with obstructive jaundice focuses on symptom management (e.g., managing pruritus with medications like cholestyramine, skin care), nutritional support (monitoring for fat-soluble vitamin deficiencies), and monitoring for complications like cholangitis.

How to Approach the Question

First, identify the key clinical findings in the patient vignette: obstructive jaundice and a palpable, non-tender gallbladder.
Recognize that this specific combination of signs is known as Courvoisier's law or sign.
Recall the principle of Courvoisier's law: it suggests a malignant obstruction rather than a benign one like gallstones.
Evaluate the options based on this principle. Ask yourself which option best explains a gradual, malignant obstruction of the distal common bile duct.
Eliminate choledocholithiasis because it typically causes a fibrotic, non-palpable (or tender) gallbladder.
Consider the most common cause for Courvoisier's sign, which is carcinoma of the head of the pancreas, making it the most likely diagnosis.

Concept Tested & Keywords

Concept Tested: The clinical application of Courvoisier's law in diagnosing the cause of obstructive jaundice.
Stem keywords: obstructive jaundice, palpable, non-tender gallbladder, pruritus, 60-year-old patient
Lead-in keywords: most likely diagnosis
Clinical cues: The combination of a palpable, non-tender gallbladder and painless jaundice is the key clinical sign, known as Courvoisier's sign.

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

E6 Medicine Davidson Principles Practice 24e p. 928-930

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