🩺 Clinical Scenario A 68-year-old man presents with progressive painless jaundice, dark urine, pale stools, pruritus and weight loss. He is febrile and hypotensive. You are the surgical SHO asked to assess and outline investigations + definitive management, including endoscopic vs surgical bypass, and supportive management of complications (e.g., encephalopathy). 🔍 Understanding the Condition ❓ What is cholangiocarcinoma? A malignant tumour of the biliary epithelium (intrahepatic, perihilar/Klatskin, or distal extrahepatic). 🚨 Immediate Concern ❓ In this unwell jaundiced patient with fever and hypotension, what are you worried about? Ascending cholangitis leading to septic shock (needs urgent antibiotics + source control via biliary drainage). 🧪 Investigations ✅ You said FBC and LFTs are already mentioned — keep them, but add the full investigation set: ❓ What blood tests will you do (in addition to FBC + LFTs)? - U&E / creatinine (AKI, baseline for contrast) - CRP - Clotting profile (PT/INR) (cholestasis → vitamin K deficiency; pre-procedure safety) - Blood cultures (before antibiotics if possible) - VBG/ABG + lactate (sepsis severity, perfusion) - Group & save / crossmatch (if unstable/procedures expected) - Tumour marker: CA 19-9 (supportive, not diagnostic) ❓ What imaging will you do for suspected cholangiocarcinoma / obstructive jaundice? Answer (core MRCS pathway): - Ultrasound abdomen (first-line to confirm duct dilatation + exclude gallstones) - CT scan (contrast, staging) – assess mass, vascular invasion, metastases, resectability - MRCP – best non-invasive delineation of level and extent of biliary obstruction/strictures - ERCP – diagnostic and therapeutic (brushings/biopsy + stenting) - PTC – if ERCP not possible/failed, especially for hilar obstruction ✅ If the exam asks “what are the key investigations?” your headline answer can be:CT + MRCP + ERCP (plus USS as initial) ⚕️ Treatment Plan ❓ What is your treatment ?

❓ What stain is used in IHC?

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Seizure and infected pseudoaneurysm