MBBS OSCE · General Surgery / Hepatobiliary

OSCE — assessment and management of obstructive jaundice in suspected pancreatic head cancer

A 10-minute OSCE station assessing the candidate's structured assessment, focused examination (Courvoisier's sign), investigation ladder, and initial management of a 68-year-old man with painless progressive jaundice and a palpable non-tender gallbladder. Tests recognition of the head-of-pancreas-cancer presentation, the differential, the first-line imaging, and the next step in treatment (Whipple in the fit patient, palliative stenting in the unfit patient).

10 min stationVerification in progress
On this page
Study tools

Exam tags

NEET-PGINICETUSMLEPLAB

Brief (to candidate)

A 68-year-old man presents to the surgical outpatient department with a six-week history of progressive, painless yellowing of the skin and sclera, dark urine, pale stools, generalised pruritus, and 8 kg of weight loss. On examination, he is deeply jaundiced, cachectic, with scratch marks on his limbs. Abdominal examination reveals a smooth, rounded, non-tender, palpable mass in the right upper quadrant that descends with respiration. No peripheral lymphadenopathy. There is no family history of cancer, but he has smoked 20 cigarettes a day for 40 years.

His investigations are: Hb 11.8 g/dL, total bilirubin 18 mg/dL (conjugated 14), ALP 480 U/L, ALT 90 U/L, AST 76 U/L, albumin 28 g/L, INR 1.4, CA 19-9 1,250 U/mL, glucose 9.2 mmol/L, HbA1c 6.4%.

You have 10 minutes to take a focused history, present your findings, propose the next investigation, and discuss the treatment plan.

Candidate instructions

  1. Take a focused history in 3 minutes — onset/tempo of jaundice, associated symptoms (pain, fever, pruritus, weight loss), risk factors (smoking, alcohol, pancreatitis, diabetes, family history), performance status.
  2. Perform a focused examination — general (cachexia, scratch marks, lymphadenopathy, Trousseau), abdominal (palpable gallbladder — Courvoisier's sign, hepatomegaly, ascites, Virchow's node).
  3. State the clinical diagnosis and the most likely underlying cause — and name the sign.
  4. Propose the next investigation — including the imaging modality, the tumour marker interpretation, the role of tissue diagnosis, and the staging workup.
  5. Outline the management — based on the assumed resectable finding on CT, including the operation, the three anastomoses, the adjuvant regimen, and the prognosis. Mention the alternative palliative pathway for an unfit patient.
  6. Communication — explain the diagnosis and the prognosis (5-year survival) honestly, and discuss the role of early palliative care.

Examiner checklist (mark each domain / 10)

DomainKey actions expected
History (focused, structured)Onset/tempo of painless progressive jaundice; pruritus; pale stools; dark urine; weight loss 8 kg; anorexia; back pain (if body/tail); risk factors: smoking 40 pack-years, new-onset glucose intolerance; family history; performance status (ECOG)[1][2]
Examination (focused, bedside)Deep jaundice + scratch marks + cachexia; lymphadenopathy (Virchow's left supraclavicular, Sister Mary Joseph periumbilical); palpable non-tender, smooth, distended gallbladder in RUQ moving with respiration — Courvoisier's sign; Trousseau thrombophlebitis; hepatomegaly; ascites; BMI/Karnofsky[2]
Clinical diagnosis + Courvoisier's lawStates painless progressive obstructive jaundice + Courvoisier's sign = malignant distal biliary obstruction (pancreatic head carcinoma until proven otherwise); states Courvoisier's law (palpable gallbladder + jaundice is unlikely to be gallstones — stones cause contracted/fibrotic GB)[1][2]
Differential (with discriminating features)Differentiates from choledocholithiasis (painful, contracted GB, cholangitis), cholangiocarcinoma (bile-duct-centred mass), ampullary carcinoma (better prognosis, visible at endoscopy), autoimmune pancreatitis (raised IgG4, sausage gland, steroid-responsive), chronic pancreatitis (calcifications, ductal changes), sclerosing cholangitis (younger, UC, multifocal strictures)[1]
Investigation ladder (with drugs, doses, timing)First-line: pancreatic-protocol triphasic CT (arterial + portal venous); CA 19-9 (note Lewis-negative 5-10% — interpret cautiously; interpret AFTER stenting); EUS-FNA for tissue before non-surgical therapy; MRCP for ductal anatomy; staging laparoscopy if borderline or CA 19-9 >500; germline testing for BRCA/PALB2/Lynch; vitamin K 10 mg IV daily × 3 days for coagulopathy; LFTs, FBC, group and save, HbA1c[1][5]
Management — curative pathway (fit patient)Resectable head mass + fit patient → Whipple (pancreatoduodenectomy) with three anastomoses: Pancreaticojejunostomy, Hepaticojejunostomy, Gastrojejunostomy (or duodenojejunostomy if pylorus-preserving); adjuvant mFOLFIRINOX for 12 cycles (PRODIGE 24, 54 vs 35 mo OS); high-volume centre; centralisation (mortality <3% vs >10%)[9]
Management — palliative pathway (unfit patient)ERCP with covered self-expanding metal stent (SEMS) for jaundice; coeliac plexus block for pain; FOLFIRINOX (if fit) or gemcitabine/nab-paclitaxel for metastatic; pancreatic enzyme replacement therapy (PERT) for steatorrhoea; early palliative care referral[1][7]
Prognosis + communicationStates 5-year survival under 10%; after R0 + mFOLFIRINOX 30-40% at 5 years; honest, empathetic, jargon-free discussion; offer support for patient and family; early palliative care referral; advanced care planning[1]
Safety-net / red flagsAdvise patient/family to seek urgent review for fever with jaundice (cholangitis), vomiting (gastric outlet obstruction), GI bleed (duodenal invasion or varices), severe back pain (progression), calf pain/swelling (DVT / Trousseau)[1]
Professionalism / handoverClear SBAR handover; MDT referral (surgical oncology, medical oncology, hepatobiliary radiology, palliative care, dietitian, genetics); stops smoking advice; germline testing offered to first-degree relatives[1]

Model key actions

  • Recognises the presentation as a textbook pancreatic head cancer: painless progressive jaundice + Courvoisier's sign (palpable non-tender GB) + weight loss + risk factors (40 pack-year smoker, new glucose intolerance, age 68).[2]
  • Names the sign and the law: Courvoisier's sign is the palpable non-tender gallbladder in a jaundiced patient; Courvoisier's law: this combination is unlikely to be due to gallstones (stones cause chronic inflammation and a fibrotic, contracted gallbladder that cannot distend).[1][2]
  • Requests the correct first-line investigation: pancreatic-protocol triphasic CT with arterial and portal-venous phases; CA 19-9 (interprets cautiously — 5 to 10% of the population are Lewis-negative and cannot produce CA 19-9); EUS-FNA for tissue diagnosis before any non-surgical therapy. Notes that stenting should precede EUS-FNA in cholangitis or in severe jaundice with coagulopathy, with vitamin K 10 mg IV daily × 3 days to correct the INR.[1]
  • Discusses resectability criteria (NCCN): ≤180° SMA/caeliac contact, no SMV/PV occlusion; only 15 to 20% are resectable at presentation. Borderline resectable → neoadjuvant FOLFIRINOX for 4 to 6 months then restaging.[1][5]
  • Names the operation and the three anastomoses: Whipple = pancreatoduodenectomy; Pancreaticojejunostomy, Hepaticojejunostomy, Gastrojejunostomy. References centralisation to high-volume centres (mortality <3%).[1]
  • Names the adjuvant regimen and trial: mFOLFIRINOX (PRODIGE 24 / ACCORD 24, Conroy 2018) — median OS 54 months vs 35 months with gemcitabine alone. Capecitabine + gemcitabine (ESPAC-4) is the alternative for less fit patients.[9]
  • Names the alternative first-line metastatic regimens and trials: FOLFIRINOX (PRODIGE 4 / ACCORD 11, Conroy 2011) — 11.1 vs 6.8 mo OS; gemcitabine + nab-paclitaxel (MPACT, Von Hoff 2013) — 8.5 vs 6.7 mo OS; olaparib maintenance for germline BRCA-mutated (POLO).[7]
  • States the prognosis honestly: 5-year survival under 10%; after R0 resection + mFOLFIRINOX 30-40% at 5 years. Discusses prognosis with patient and family in a sensitive, jargon-free way; offers early palliative care (Temel 2010 effect — improved QoL and survival).[1]
  • Reviews the smoking history, the new-onset glucose intolerance (paraneoplastic), and offers germline testing for all first-degree relatives.[1]

Common errors

  • Missing Courvoisier's sign on abdominal examination — failing to inspect, palpate, and percuss the right upper quadrant carefully for a smooth, non-tender, distended gallbladder.
  • Mistaking painless jaundice for gallstones without a CT — gallstones are common, but painless progressive jaundice in an older patient with weight loss is malignant until proven otherwise.
  • Not doing a pancreatic-protocol CT — single-phase contrast CT misses the arterial-phase assessment of SMA/coeliac encasement that determines resectability.
  • Interpreting CA 19-9 incorrectly — failing to recognise the Lewis-negative pitfall (5 to 10% of patients cannot produce CA 19-9); failing to note that CA 19-9 normalises with biliary decompression independent of tumour response.
  • Forgetting EUS-FNA for tissue before any non-surgical therapy (neoadjuvant, palliative chemotherapy).
  • Forgetting vitamin K in an obstructed, coagulopathic patient before any invasive procedure.
  • Calling Whipple "the three-anastomosis operation" but failing to name the three anastomoses (pancreaticojejunostomy, hepaticojejunostomy, gastrojejunostomy).
  • Not naming the landmark trial that supports the adjuvant or metastatic regimen (PRODIGE 24 for mFOLFIRINOX adjuvant, PRODIGE 4 for FOLFIRINOX metastatic, MPACT for gem/nab, POLO for olaparib).
  • Not offering early palliative care — the Temel 2010 trial (NEJM) showed early palliative care improved both quality of life and survival in metastatic lung cancer, replicated in PDAC cohorts; the candidate is expected to mention it.
  • Not offering germline testing to the patient and first-degree relatives — BRCA1/2/PALB2/ATM are now found in 4 to 10% of unselected PDAC, with major implications for relatives and for PARP-inhibitor therapy.
  • Not discussing smoking cessation, weight loss, PERT, or dietitian input — all of which are part of comprehensive care.
  • Giving an unrealistic prognosis — the 5-year survival is under 10% overall, and even after R0 + mFOLFIRINOX is 30-40%; over-promising is a common candidate error.
References5Show
  1. [1]Park W, Chawla A, O'Reilly EM Pancreatic Cancer: A Review. JAMA, 2021.PMID 34547082
  2. [2]McGuigan A, Kelly P, Turkington RC, et al. Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes. World Journal of Gastroenterology, 2018.PMID 30487695
  3. [5]Kamisawa T, Wood LD, Itoi T, Takaori K Pancreatic cancer. Lancet, 2016.PMID 26830752
  4. [7]Conroy T, Desseigne F, Ychou M, et al. FOLFIRINOX versus gemcitabine for metastatic pancreatic cancer. N Engl J Med, 2011.PMID 21561347
  5. [9]Conroy T, Hammel P, Hebbar M, et al. FOLFIRINOX or Gemcitabine as Adjuvant Therapy for Pancreatic Cancer. N Engl J Med, 2018.PMID 30575490
OSCE — assessment and management of obstructive jaundice in suspected pancreatic head cancer · MBBS OSCE · NeetVellum