A 65-year-old man comes to the emergency department because of worsening generalized itching for 7 days. He has experienced abdominal discomfort, bloating, and decreased appetite for several weeks. He states that he has lost 10-12 lbs (4.5-5.4 kg) during this time, which he attributes to excessive stress at work. He denies nausea, vomiting, diarrhea, easy bleeding, or bruising.
His temperature is 36.9 C (98.4 F), blood pressure is 123/70 mm Hg, and pulse is 78/min and regular. On examination, he has icteric conjunctivae and skin. He has bilateral diffuse scratch marks. There is mild tenderness on palpation of his right upper abdominal quadrant. The tip of the spleen is not palpable.
Laboratory results are as follows:

Abdominal ultrasound reveals an enlarged liver with dilated intrahepatic bile ducts. A CT scan of the abdomen reveals an ill-defined 3.5 cm pancreatic mass and several low-attenuating foci in the liver consistent with metastasis.
Which of the following would be the best next step in managing this patient?

Question

A 65-year-old man comes to the emergency department because of worsening generalized itching for 7 days.  He has experienced abdominal discomfort, bloating, and decreased appetite for several weeks.  He states that he has lost 10-12 lbs (4.5-5.4 kg) during this time, which he attributes to excessive stress at work.  He denies nausea, vomiting, diarrhea, easy bleeding, or bruising.
His temperature is 36.9 C (98.4 F), blood pressure is 123/70 mm Hg, and pulse is 78/min and regular.  On examination, he has icteric conjunctivae and skin.  He has bilateral diffuse scratch marks.  There is mild tenderness on palpation of his right upper abdominal quadrant.  The tip of the spleen is not palpable.
Laboratory results are as follows:

Abdominal ultrasound reveals an enlarged liver with dilated intrahepatic bile ducts.  A CT scan of the abdomen reveals an ill-defined 3.5 cm pancreatic mass and several low-attenuating foci in the liver consistent with metastasis.
Which of the following would be the best next step in managing this patient?

Quizplus · Accepted Answer

Pancreatic cancer has the highest mortality among all gastrointestinal cancers and is diagnosed at a median age of 71. The majority (80-85%) of patients present with unresectable or metastatic disease. Median survival is typically 3 to 6 months. Chemotherapy is a consideration for patients with locally advanced disease that is not surgically resectable. However, the treatment is palliative for metastatic pancreatic cancer to the liver. Up to 70% of patients with pancreatic cancer develop symptomatic biliary obstruction, which increases the risk for cholangitis. Biliary endoscopic stenting is preferred for relieving the obstruction prior to considering the administration of systemic chemotherapy (Choice B). Surgical biliary decompression (e.g., cholecystojejunostomy or choledochojejunostomy) is reserved for patients who cannot undergo endoscopic stenting due to technical reasons (Choice A). (Choice D) Narcotic medications are often required for moderate to severe pain associated with locally advanced pancreatic cancer; however, these medications can exacerbate itching due to histamine release. This patient's main complaint is itching, not pain. (Choice E) Ursodeoxycholic acid reduces hepatic cholesterol secretion and fractional intestinal cholesterol reabsorption to decrease biliary cholesterol content. It can possibly prevent gallstone formation and dissolve gallstones in primary biliary cirrhosis but is not as beneficial in metastatic pancreatic cancer patients with obstructive jaundice. Educational objective: Pancreatic cancer patients commonly present with biliary obstruction. Endoscopic stent placement is preferred to relieve biliary obstruction and prevent cholangitis. __________ References: Treatment of pancreatic cancer: challenge of the facts (http://www.ncbi.nlm.nih.gov/pubmed/12925907) Palliative therapy for pancreatic/biliary cancer (http://www.ncbi.nlm.nih.gov/pubmed/15833477)

A 65-Year-Old Man Comes to the Emergency Department Because of Worsening