A 56-year-old man comes to the office due to 2 months of upper abdominal discomfort, bloating, and anorexia. Over this period, the patient has had no nausea, vomiting, or black/tarry stools but has lost 8 kg (17.6 lb) . He has a history of hypertension and gout. The patient is an active smoker with a 45 pack-year history and drinks alcohol occasionally. He traveled to Mexico 3 months ago for vacation.
Temperature is 37.2 C (99 F) , blood pressure is 120/70 mm Hg, pulse is 86/min, and respirations are 12/min. BMI is 29 kg/m². Scleral icterus is present. The abdomen is soft and nondistended. There is mild right upper quadrant discomfort on deep palpation. The liver edge is palpable 3 cm below the right costal margin. Stool testing for occult blood is negative. The remainder of the physical examination shows no abnormalities.
Laboratory results are as follows:
Abdominal ultrasound shows dilated intrahepatic and extrahepatic bile ducts. The gallbladder is enlarged but no gallstones are visualized.
Which of the following is the best next step in management of this patient?

Question

A 56-year-old man comes to the office due to 2 months of upper abdominal discomfort, bloating, and anorexia. Over this period, the patient has had no nausea, vomiting, or black/tarry stools but has lost 8 kg (17.6 lb) . He has a history of hypertension and gout. The patient is an active smoker with a 45 pack-year history and drinks alcohol occasionally. He traveled to Mexico 3 months ago for vacation.
Temperature is 37.2 C (99 F) , blood pressure is 120/70 mm Hg, pulse is 86/min, and respirations are 12/min. BMI is 29 kg/m². Scleral icterus is present. The abdomen is soft and nondistended. There is mild right upper quadrant discomfort on deep palpation. The liver edge is palpable 3 cm below the right costal margin. Stool testing for occult blood is negative. The remainder of the physical examination shows no abnormalities.
Laboratory results are as follows:

Abdominal ultrasound shows dilated intrahepatic and extrahepatic bile ducts. The gallbladder is enlarged but no gallstones are visualized.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_97f7_ceb8_853d_891416e371be_MD0002_00 This patient's presentation is most consistent with extrahepatic biliary obstruction. The differential diagnosis includes choledocholithiasis, stricture, pancreatic pathology, and malignancy of the biliary tree. Diagnostic evaluation usually begins with transabdominal ultrasound. However, this test may miss pancreatic lesions due to overlying bowel gas, small lesion size (<3 cm), or lack of skill of the operator. Given the high pretest probability of cancer in this patient (weight loss, anorexia, jaundice, smoking history), the best next step is a helical abdominal CT scan to evaluate for pancreatic malignancy. If CT scan reveals a pancreatic mass, histological diagnosis is then generally made with endoscopic ultrasound-guided fine-needle aspiration. (Choice A) Primary biliary cholangitis is also associated with elevated alkaline phosphatase and cholestatic jaundice but is not typically associated with extrahepatic biliary duct dilation or gallbladder enlargement. Liver biopsy shows inflammation confined to the portal and periportal areas, bridging fibrosis, and/or cirrhosis. (Choices C and D) Both endoscopic retrograde cholangiopancreatography (ERCP) and MR cholangiopancreatography can be used to evaluate the pancreatobiliary tree; ERCP has the added benefit of being able to provide a therapeutic intervention (eg, stent placement). These tests are superior to abdominal CT scan when choledocholithiasis is suspected. However, patients who require imaging of the pancreas for suspected cancer (as in this patient with heavy tobacco use, weight loss, abdominal pain, jaundice, and no gallstones on ultrasound) should first undergo abdominal CT scan as it is lower cost, less invasive, associated with fewer complications, and can provide staging information. If CT shows pancreatic cancer causing biliary obstruction, ERCP with stenting is sometimes used for palliation or as a bridge to surgery. (Choice E) Viral hepatitis typically causes elevation of both AST and ALT without dilated intrahepatic or extrahepatic bile ducts. Although this patient went to Mexico recently, the relatively normal AST and ALT makes this diagnosis less likely. Educational objective: Patients with jaundice and abdominal pain should be evaluated for gallstones with ultrasound. Those who have no evidence of gallstones should undergo CT scan of the abdomen to evaluate for pancreatic pathology, particularly if there are signs (eg, unintentional weight loss) concerning for malignancy. Depending on CT scan findings, further evaluation with endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, or MR cholangiopancreatography is often required. __________ References: Diagnosis of pancreatic cancer. Page(s): PMC2020745 (http://www.ncbi.nlm.nih.gov/pubmed/18333085)

A 56-Year-Old Man Comes to the Office Due to 2