Cholangiocarcinoma

A 44-year-old female comes to her primary care provider due to fatigue and intense pruritus for the last 2 months. She works as a schoolteacher and has felt excessive daytime somnolence that is interfering with her job. Past medical history is significant for chronic autoimmune (Hashimoto) thyroiditis, for which she has been taking daily levothyroxine. She drinks 1-2 glasses of wine on the weekends and denies smoking tobacco or using illicit substances. Her temperature is 37.2°C (99.0°F), pulse is 82/min, respirations are 12/min, and blood pressure is 128/82 mmHg. Physical examination reveals multiple excoriations on her trunk and extremities. The liver is palpated 4 cm below the costal margin and is not tender to palpation. Laboratory results are as follows:



Which of the following complications is associated with this patient’s disease process?