A 72-year-old man presents to the emergency department with 4 weeks of progressive painless jaundice, dark urine, pale stools, a 7 kg weight loss and severe generalized itching that disrupts his sleep. He has severe COPD (FEV1 30% predicted) and heart failure with atrial fibrillation (LVEF 25%); his ECOG performance status is 3. His medications are furosemide, digoxin and tiotropium. On examination he is deeply jaundiced with widespread excoriations; the abdomen is soft and non-tender. Total bilirubin is 310 µmol/L (less than 21), conjugated bilirubin 270 µmol/L (less than 5), ALP 720 U/L (40-129), ALT 120 U/L (less than 41) and INR 1.5 (0.9-1.2). Contrast CT shows a 3 cm hypoattenuating mass in the pancreatic head with abrupt cut-off of the distal common bile duct and marked dilatation of the common bile duct and intrahepatic ducts; the gallbladder is distended. The surgical and anesthesia teams conclude that he is not fit for any operation.
| Heart rate | 88/min |
| Respiratory rate | 20/min |
| Temperature | 36.9 °C |
| O2 saturation | 91%, room air |
| Blood pressure | 118/72 mm Hg |
Question 1 of 3
Which one of the following is the most appropriate intervention to relieve this patient's biliary obstruction?
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