Last reviewed: 6 May 2023
Last updated: 09 Feb 2023



History and exam

Key diagnostic factors

  • painless jaundice
  • weight loss
  • abdominal pain
More key diagnostic factors

Other diagnostic factors

  • pruritus
  • triad of fever, jaundice, and RUQ pain
  • palpable gallbladder
  • hepatomegaly
  • dark urine
  • pale stools
  • asymptomatic
Other diagnostic factors

Risk factors

  • age >50 years
  • cholangitis
  • choledocholithiasis
  • cholecystolithiasis
  • other structural disorders of the biliary tract
  • ulcerative colitis (UC)
  • primary sclerosing cholangitis (PSC)
  • nonspecific cirrhosis
  • alcoholic liver disease
  • liver fluke infection
  • chronic typhoid carrier
  • hepatitis C virus (HCV)
  • HIV
  • hepatitis B virus (HBV)
  • exposure to thorium dioxide
  • diabetes
  • cigarette smoking
  • exposure to toxins/medications
  • male sex
More risk factors

Diagnostic investigations

1st investigations to order

  • serum bilirubin
  • serum alkaline phosphatase
  • serum gamma-GT
  • serum aminotransferase
  • serum prothrombin time
  • serum CA 19-9
  • serum carcinoembryonic antigen (CEA)
  • serum CA-125
  • abdominal ultrasound
  • abdominal CT
  • abdominal MRI
More 1st investigations to order

Investigations to consider

  • endoscopic ultrasound (EUS)
  • MR angiography
  • ERCP
  • MRCP
  • percutaneous transhepatic catheterization (PTC)
  • positron emission tomography (PET)
  • Immunostaining
More investigations to consider

Emerging tests

  • optical coherence tomography (OCT)
  • peroral cholangioscopy
  • duodenoscope-assisted cholangioscopy

Treatment algorithm


resectable disease

unresectable disease



N. Joseph Espat, MD, MS, FACS

Chairman of Surgery

Professor and Chief Surgical Oncology

Director Cancer Center

Department of Surgery

Roger Williams Medical Center

Boston University School of Medicine




NJE declares he has no competing interests.

Ponnandai Somasundar, MD, MPH, FACS

Associate Professor and Associate Chief

Surgical Oncology

Department of Surgery

Roger Williams Medical Center

Boston University School of Medicine




PS is an advisory board member for RWMC, and a clinical board consultant for Medtronic HPB.

Peer reviewers

Kevin Watkins, MD

Assistant Professor

Department of Surgery

Health Science Center


Stony Brook



KW declares that he has no competing interests.

Savio Reddymasu, MD

GI Fellow

Department of Medicine

Center for Gastrointestinal Motility

Division of Gastroenterology and Hepatology

University of Kansas Medical Center

Kansas City



SR declares that he has no competing interests.

Satvinder Mudan, MBBS, BSc, MD, FRCS

Consultant in Surgical Oncology

The Royal Marsden Hospital




SM declares that he has no competing interests.

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