Remarkable dilation of the common bile duct in an elderly patient

A 78-year-old male without relevant medical history was submitted to Endoscopic Retrograde Cholangiopancreatography (ERCP) for acute cholangitis. Prior abdominal CT scan showed excessively dilated common bile duct (CBD) of 35mm and no evidence of choledocholithiasis (Fig. 1a); an abrupt stop in the distal CBD suggesting malignant stricture was also seen (Fig. 1b). Duodenoscopic examination revealed a 20mm sized bulging nodular lesion with congestive and irregular mucosal surface at the major duodenal papilla (Fig.2); ERCP performed showed a distal stricture and CBD with 38mm diameter (Fig. 3).