Introduction

A 70-year-old man with an unremarkable medical history presented to the emergency department with a 2-week history of dark urine, pale stools and diffuse abdominal discomfort. He could not tolerate any oral intake secondary to significant emesis within 1–2 hours of eating. He endorsed a 5 kg weight loss since onset of symptoms. The patient was clinically jaundiced, and abdominal examination was normal. Blood tests showed elevated aspartate aminotransferase 88 U/L, alanine aminotransferase 238 U/L, alkaline phosphatase 396 U/L, total bilirubin 339 µmol/L, direct bilirubin 311 µmol/L and carbohydrate antigen 19–9 295 U/mL. After intravenous hydration, he underwent abdominal ultrasound, which showed pancreatic and intrahepatic biliary duct dilation with no visible stone. Abdominal CT is shown in figure 1. Esophagogastroduodenoscopy noted duodenal stenosis from the apex of the bulb through …