A 65-year-old man comes to the office due to progressive weight loss, jaundice, and anorexia over the last 3 months. His urine has been dark and his stools have been pale. The patient has no prior medical conditions and takes no medications. He has smoked a pack of cigarettes a day for 40 years. He drinks 2 cups of coffee every day and 1 or 2 glasses of wine on most nights. He used illicit drugs for 2 years when he was in his teens but has used none since. The patient has a sedentary lifestyle and frequently consumes red and processed meats. Vital signs are within normal limits. BMI is 28 kg/m². Physical examination shows scleral icterus. The chest is clear to auscultation and percussion. Abdominal examination shows an enlarged but nontender gallbladder. There is no ascites. Which of the following is the strongest factor predisposing to this patient's current condition?

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11ec160b_3958_1d31_9249_85a19c5c787f_MD0001_00 Pancreatic adenocarcinoma should be considered in any patient with painless obstructive jaundice (elevated bilirubin, dark urine, pale stools) and weight loss. Courvoisier sign (painless palpable gallbladder in a jaundiced patient) can also raise suspicion, although this can be seen in a number of conditions (eg, cholangiocarcinoma, hepatic duct obstruction). Symptoms of pancreatic malignancy vary with location; tumors at the pancreatic head typically produce obstructive symptoms due to compression of the common bile duct (CBD), whereas those in the body and tail do not obstruct the CBD and often produce midepigastric pain due to invasion of the splanchnic plexus. Smoking is the most important environmental risk factor for pancreatic cancer and doubles the risk. (Choice A) Alcohol consumption increases the risk of malignant tumors involving the head, neck, esophagus, and liver. Chronic alcohol consumption can cause chronic pancreatitis, but moderate alcohol use in the absence of chronic pancreatitis does not appear to confer any additional risk for pancreatic cancer. (Choice C) Chronic, heavy intake of hot beverages is associated with increased risk for esophageal cancer, but coffee intake does not increase the risk of pancreatic cancer. (Choices D and E) A low-fiber diet and diets high in processed meats are associated with an increased risk of colon adenocarcinoma. (Choice F) Chronic viral hepatitis B and C greatly increase the risk of hepatocellular carcinoma. They may increase the risk of pancreatic cancer, but only slightly. Educational objective: Smoking is the most important environmental risk factor for pancreatic cancer. Other risk factors include advanced age, chronic pancreatitis, and genetic predisposition (eg, Peutz-Jeghers syndrome). __________ References: Alcohol intake and pancreatic cancer: A pooled analysis from the pancreatic cancer cohort consortium (PanScan). (http://www.ncbi.nlm.nih.gov/pubmed/20373013)

A 65-Year-Old Man Comes to the Office Due to Progressive