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Answer 5
    Pancreatic adenocarcinoma. The patient presents with classic signs of pancreatic adenocarcinoma—painless jaundice, weight loss, and anorexia in the setting of recently diagnosed diabetes. The cholangiogram demonstrates a long, tight distal CBD stricture (Figure 2). The distal CBD runs through the head of the pancreas (the most common site for pancreatic adenocarcinoma), and in this patient, the CBD is extrinsically compressed by a tumor mass. Cholangiocarcinoma at this site is possible but markedly less common. Although a postoperative biliary stricture is possible, it is very unlikely to develop in the intrapancreatic portion of the CBD due to its limited accessibility. Ampullary cancer could present with similar symptoms and laboratory profile but would likely demonstrate a site of obstruction in the most distal portion of the CBD at the level of the ampulla/duodenal wall and not higher up the duct, as seen in this patient. Cholecystitis is not possible in this patient, as she has undergone cholecystectomy, evidenced by the absence of a gallbladder and the postsurgical clip seen on the cholangiogram.

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