A 54-year old woman presented to hospital with two days of epigastric pain, nausea and vomiting. Her history was significant for malignant melanoma of the right leg, diagnosed five years earlier, with subsequent endometrial, breast, lung and cerebral metastases. Liver enzyme levels were elevated (aspartate aminotransferase 230 IU/L, alanine aminotransferase 336 IU/L), with a total bilirubin level of 178 μmol/L. Computed tomography scanning demonstrated biliary dilation and a distal common bile duct (CBD) mass
