A 70-year-old man complained of painless progressive jaundice and pale stools for 2 months, loss of weight and appetite recently. General examination showed a cachectic and jaundiced patient. A vague epigastric mass was detected on abdominal examination. Laboratory investigations revealed hyper- bilirubinaemia and a raised alkaline phosphatase level. The clinical diagnosis of obstructive jaundice was suggested and a contrast enhanced CT was performed for further evaluation (shown below).

1. Describe the scan in details and give the possible diagnosis with rational?
2. Mention two additional nuclear medicine imaging scans you can request in this case, give detailed possible findings and justifications for each?
3. How would you manage this patient? Outline your detailed management plan (including the pros and cons)?

Obstructive jaundice occurs when there is an obstacle to the free flow of bile between the producing site (hepatocyte) and the duodenum and is caused by drugs, immunological diseases, congenital disorders, parasites, stones or tumors.

1. Describe the exam in detail and give the possible diagnosis with rationality?

In the imaging exam it is possible to visualize the obstruction giving the certainty of obstructive jaundice, as the most common signs found in patients with liver disease are found in this patient

2. Mention two additional nuclear medicine imaging tests that you may order in this case, provide possible findings and detailed rationale for each?

Ultrasonography (US) is currently a widely available method for studying jaundice due to obstruction, associating characteristics of low cost economic to a resolving power, and the Nuclear magnetic resonance (NMR) is a imaging method based on the physical phenomenon of absorption and re-emission of electromagnetic radiation by atoms subjected to very strong electromagnetic fields.

3. How would you treat this patient? Describe your detailed management plan (including pros and cons)?

The treatment of obstructive jaundice fundamentally depends on its cause. In cases of stones in the bile ducts, the ideal treatment, whenever possible, is ERCP (endoscopic examination that allows contrasting the bile duct, duodenal route, identifying the cause of obstruction and removing stones when present).

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