A 58-year-old male with a history of alcohol use presents with painless jaundice, dark urine, pale stools, and weight loss of 8 kg over 2 months. Physical examination reveals a palpable, non-tender gallbladder (Courvoisier's law positive). Abdominal CT demonstrates a 3 cm mass in the head of the pancreas causing dilation of both the common bile duct and the pancreatic duct ('double duct sign'). What is the most likely diagnosis?

Answer and explanation

Correct answer: C. Pancreatic Ductal Adenocarcinoma of the pancreatic head

  1. Step 1: Courvoisier's law states that in the presence of painless jaundice, a palpable non-tender gallbladder is unlikely to be caused by gallstones (as chronic cholelithiasis causes fibrotic, non-distensible gallbladders) and is typically caused by an obstructing malignancy of the biliary tree or pancreatic head.
  2. Step 2: The 'double duct sign' (simultaneous dilation of the common bile duct and main pancreatic duct) on CT or MRCP is classic for Pancreatic Head Adenocarcinoma.
  3. Step 3: Surgical resection via pancreaticoduodenectomy (Whipple procedure) is the definitive curative option in resectable cases.
Answer
Pancreatic Ductal Adenocarcinoma of the pancreatic head.
Why not the others: 'Acute calculous cholecystitis' presents with severe RUQ pain, fever, Murphy sign, and shrunken gallbladder; 'Chronic pancreatitis' causes calcifications and pain without painless obstructive jaundice and palpable gallbladder; 'Choledocholithiasis' presents with colicky pain and non-palpable gallbladder.

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