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1) The resident is feeling a distended gallbladder.

2) Fig A shows an abnormally large gallbladder without stones, and a prominent bile duct in the head of the pancreas. Fig B shows distended intrahepatic bile ducts (dark, tubular strictures within the liver).

3) Adenocarcinoma of the head of the pancreas. The presence of a palpable gallbladder in the setting of painless obstructive jaundice is called Courvoisier's Sign (After Swiss surgeon, Ludwig Courvoisier 1843-1918) (or sometimes Courvoisier's Law).

4) Placement of a biliary endoprosthesis across the (probable) distal bile duct stricture will allow the jaundice to resolve. The choice between plastic and metal stents depends on whether the patient is a potential candidate for surgery (Whipple procedure). Surgeons prefer not to have metal stents in the bile duct when they operate. Early surgery without preoperative drainage is an option in the asymptomatic patient that some surgeons prefer. This reduces this risk of perioperative infections resulting from instrumentation of the biliary tree.

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