A 58-year-old man comes to the office due to yellowish discoloration of the skin, anorexia, and unintentional weight loss of 6 kg (13.2 lb) over the past 3 months. He also reports dark urine and pale stools. The patient has had no fever, abdominal pain, constipation, or diarrhea. He has a history of hypertension and hyperlipidemia. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are within normal limits. BMI is 32 kg/m². Scleral icterus is present. An enlarged, nontender gallbladder is palpated below the right costal margin. There is no ascites. Abdominal imaging in this patient is most likely to reveal which of the following findings?

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11ec25c8_d0d8_d233_bc81_0db44b5aeca6_MD0003_00 This patient with painless jaundice, weight loss, anorexia, and a palpable gallbladder most likely has pancreatic cancer. Most (60%-70%) pancreatic tumors occur in the head of the pancreas, which is in close proximity to the biliary tree. As these tumors expand, they can compress the common bile duct (CBD), resulting in backup of bile with subsequent intra- and extrahepatic biliary duct dilation. When the tumor also compresses the pancreatic duct, a double duct sign (ie, dilation of both the common bile duct and the pancreatic duct) can be seen radiographically, which is further suggestive of advanced neoplasia. double duct sign Symptoms of pancreatic cancer occurring at the head of the pancreas include painless jaundice (eg, yellowish skin, pruritus, pale stools, dark urine) and a nontender, distended gallbladder at the right costal margin (Courvoisier sign). In contrast, cancers in the body or tail of the pancreas usually present with abdominal pain but without jaundice since they do not typically obstruct the biliary system. (Choice A) Pancreatic cystic lesions are usually asymptomatic. Jaundice is unexpected in a pancreatic tail lesion due to the distance from the biliary tree. (Choice B) Gallstone obstruction of the cystic duct can cause biliary colic (ie, intermittent right upper quadrant [RUQ] pain) or cholecystitis (ie, RUQ pain, leukocytosis, fever). However, because the CBD is not obstructed, jaundice does not occur. In addition, gallbladder tenderness is expected, and weight loss would be atypical. (Choice D) Pyogenic liver abscesses are identified radiographically as multiloculated, hypoechoic hepatic lesions that present with jaundice and weight loss. However, fevers and leukocytosis are expected, and an enlarged gallbladder would be atypical. (Choice E) Encapsulated peripancreatic fluid collections (eg, pseudocysts) occur in patients with a history of pancreatitis and are usually asymptomatic but can cause epigastric pain and early satiety. Pseudocysts are almost never located close enough to the biliary tree to cause obstruction; therefore, jaundice and gallbladder enlargement are unexpected. (Choice F) Portal vein thrombosis (PVT) is most often associated with cirrhosis. Acute PVT usually presents with abdominal pain, whereas chronic PVT most often presents with variceal bleeding. This patient's weight loss, jaundice, and palpable gallbladder is more consistent with pancreatic cancer. chronic PVT Educational objective: Tumors in the head of the pancreas can present with weight loss, jaundice, and a nontender, distended gallbladder (eg, Courvoisier sign) on examination. Imaging can demonstrate dilation of both the intra- and extrahepatic bile ducts as well as the pancreatic duct (ie, double duct sign). References: Imaging diagnosis of pancreatic cancer: a state-of-the-art review. (http://www.ncbi.nlm.nih.gov/pubmed/24976723)

A 58-Year-Old Man Comes to the Office Due to Yellowish