A 68-year-old woman presents to the emergency department complaining of fatigue and intermittent vague abdominal pain. She denies nausea or vomiting but “does not have much of an appetite these days.” She reports unintentionally losing almost 20 lbs. in the past two months. She was recently diagnosed with type 2 diabetes, but she has no other medical problems and no previous surgeries. Her stools have become lighter in color, and her urine is much darker than before. Her social history is negative for alcohol use, but she has a 50+ pack-year smoking history before quitting last year. She has no significant family history. On exam, she has a yellow hue to her eyes and tongue, along with scratch marks on her skin. A non-tender mass is palpated in the right upper quadrant (RUQ) of the abdomen. Laboratory testing reveals total and direct bilirubin of 18 mg/dl (normal 0.2–1.3 mg/dl) and 9.2 mg/dl (<0.3 mg/dl), respectively, and alkaline phosphatase (ALP) of 215 μ/L (33–131 μ/L). Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) are mildly elevated. CA 19-9 and CEA levels are normal.