A 48-year-old woman comes into the ward with a 1-day history of yellowish discolouration of skin and sclera. Abdominal examination reveals a palpable mass that is non-tender in the right upper quadrant. The urine sample shows dark urine.

What is the most likely diagnosis?

Options:
explanation: This is not the correct answer. Dark urine implies conjugated hyperbilirubinemia as conjugated bilirubin is water-soluble, and this is found in hepatic (hepatocellular) and post-hepatic (obstructive) jaundice. Cholecystitis can be caused by various hepatic and post-hepatic causes, however, it will most likely present with a positive Murphy's sign upon palpation of the right upper quadrant, and not a non-tender palpable mass. A non-tender palpable mass in the right upper quadrant accompanied with jaundice implies a positive Courvoisier sign, where the cause of the obstructive jaundice is likely to be a head of pancreas malignancy until proven otherwise.
name: Cholecystitis
label: c
answer: no
explanation: This is not the correct answer. Hepatocellular carcinoma (HCC) is a primary tumour of the liver that can be a cause of hepatic jaundice, which presents with a mix of unconjugated and conjugated hyperbilirubinemia. Liver cirrhosis-related HCC patients can present with jaundice and a palpable mass, however, it would not present as suddenly as the patient in the scenario and it is usually accompanied by other symptoms such as pruritus, ascites, cachexia (weight loss, early satiety), fever, malaise and so forth. A non-tender palpable mass in the right upper quadrant accompanied with jaundice implies a positive Courvoisier sign, where the cause of the obstructive jaundice is likely to be a head of pancreas malignancy until proven otherwise.
name: Hepatocellular carcinoma
label: e
answer: no
explanation: This is not the correct answer. Dark urine implies conjugated hyperbilirubinemia as conjugated bilirubin is water-soluble, and this is found in hepatic (hepatocellular) and post-hepatic (obstructive) jaundice. Gallstones are indeed a post-hepatic cause of jaundice, however, palpation of the right upper quadrant will most likely elicit a positive Murphy's sign where pain occurs while palpating the right subcostal area while the patient is asked to take in and hold a deep breath as the inflamed gall bladder comes into contact with the examiner's hand, especially if there is gallstone induced cholecystitis present. A non-tender palpable mass in the right upper quadrant accompanied with jaundice implies a positive Courvoisier sign, where the cause of the obstructive jaundice is likely to be a head of pancreas malignancy until proven otherwise.
name: Gallstones
label: b
answer: no
explanation: This is the correct answer. Dark urine implies conjugated hyperbilirubinemia as conjugated bilirubin is water-soluble, and this is found in hepatic (hepatocellular) and post-hepatic (obstructive) jaundice. A non-tender palpable mass in the right upper quadrant accompanied with jaundice implies a positive Courvoisier sign, where the cause of the obstructive jaundice is likely to be a head of pancreas malignancy until proven otherwise. Cholangiocarcinomas can also present with a positive Courvoisier sign
name: Head of pancreas malignancy
label: a
answer: yes
explanation: This is not the correct answer. Gilbert's syndrome is an autosomal recessive disorder of bilirubin metabolism in the liver due to a defect in the UDP-glucuronosyltransferase 1 gene. It is a pre-hepatic cause of jaundice which presents with unconjugated hyperbilirubinemia, unlike the scenario in the question. In addition, a non-tender palpable mass in the right upper quadrant accompanied with jaundice implies a positive Courvoisier sign, where the cause of the obstructive jaundice is likely to be a head of pancreas malignancy until proven otherwise.
name: Gilbert's syndrome
label: d
answer: no

Correct answer: a