**Question:** A 67-year-old woman is evaluated for obstructive jaundice. The cholangiographic findings indicate that she has a cancer of the lower end of the CBD. Clinical examination would most likely reveal which of the following?

A. Right upper quadrant tenderness
B. Direct tenderness over the lower end of CBD
C. Indirect tenderness over the liver
D. Altered bowel sounds

**Correct Answer:** .

**Core Concept:**

Obstructive jaundice is a condition characterized by the buildup of bilirubin in the blood due to bile duct obstruction, leading to clinical manifestations such as hyperbilirubinemia and itching. In patients with cholangiographic findings indicative of a lower end of the CBD (common bile duct) cancer, the clinical examination would focus on assessing the presence of biliary obstruction-related symptoms and signs.

**Why the Correct Answer is Right:**

The correct answer is **A** (Right upper quadrant tenderness) because obstructive jaundice typically presents with right upper quadrant tenderness due to the compression of the liver by the enlarged gallbladder or tumor. The lower end of the CBD cancer, causing obstruction, would lead to increased pressure within the liver and the right liver lobe, resulting in tenderness upon palpation.

**Why Each Wrong Option is Incorrect:**

**B (Direct tenderness over the lower end of CBD)** is incorrect because in cases of lower end of CBD obstruction, the tenderness would be more likely to be felt over the liver rather than the lower end of the CBD.

**C (Indirect tenderness over the liver)** is also incorrect because the tenderness in this case would be due to the raised pressure within the liver, not direct tenderness over the liver itself.

**D (Altered bowel sounds)** is unrelated to the clinical presentation of obstructive jaundice and is therefore incorrect. Jaundice is primarily caused by the obstruction of the bile ducts, leading to the accumulation of bilirubin, and not bowel sound abnormalities.

**Clinical Pearl:**

In obstructive jaundice, it is crucial to differentiate between right upper quadrant tenderness (Option A) and indirect tenderness over the liver (Option C). Proper clinical examination skills, including the ability to palpate the liver and biliary tracts accurately, are essential to make an accurate diagnosis. Appropriate history-taking and examination findings will guide the diagnostic and management decisions in this scenario.