A 54-year-old man comes to the physician complaining of fatigue. It is difficult for him to get up in the morning and go to work. He tires easily at work and goes to bed early due to feeling tired and sleepy. He also describes recent upper abdominal pain that is constant and gnawing and interferes with his sleep. The patient's appetite is poor, and he has lost 7 kg (15 lb) during the last month. He has no other medical problems. His medications include over-the-counter ranitidine. The patient works as a police officer. Two months ago, while investigating a serious crime scene, he slipped on blood, fell, and hit his head. He is a former smoker with a 30-pack-year history. Physical examination is significant for tenderness and fullness in the epigastrium. Which of the following is the most likely diagnosis?

Question

A 54-year-old man comes to the physician complaining of fatigue.  It is difficult for him to get up in the morning and go to work.  He tires easily at work and goes to bed early due to feeling tired and sleepy.  He also describes recent upper abdominal pain that is constant and gnawing and interferes with his sleep.  The patient's appetite is poor, and he has lost 7 kg (15 lb) during the last month.  He has no other medical problems.  His medications include over-the-counter ranitidine.  The patient works as a police officer.  Two months ago, while investigating a serious crime scene, he slipped on blood, fell, and hit his head.  He is a former smoker with a 30-pack-year history.  Physical examination is significant for tenderness and fullness in the epigastrium.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d2e3_20c0_bc81_01e688c6d8e8_MD0003_00 This patient has epigastric pain/tenderness and weight loss in the setting of nonspecific systemic symptoms and a significant smoking history. This combination strongly suggests a malignancy affecting the upper gastrointestinal tract or associated solid organs, such as the liver, gallbladder, or pancreas. Among the choices listed, pancreatic adenocarcinoma is the most likely diagnosis. Adenocarcinoma of the pancreas is the fourth leading cause of cancer-related death in the United States and has a mean age of 55 at diagnosis. Smoking is an important risk factor. Pancreatic cancer has a very high mortality rate as it is frequently diagnosed at relatively late stages (early-stage disease usually causes only mild, nonspecific symptoms). Symptoms of pancreatic cancer vary and depend primarily on the location of the tumor. Most (60%-70%) pancreatic cancers originate in the head of the pancreas. These cancers are more likely to present with jaundice (common bile duct obstruction) and steatorrhea (inability to secrete fat-digesting enzymes or blockage in the main pancreatic duct). However, jaundice may appear at a later stage if the tumor arises from the tail or body of the pancreas. Most patients describe epigastric abdominal pain that is usually insidious, gnawing, and worse at night. However, some patients may not have pain and simply present with painless jaundice. Systemic symptoms such as weight loss and fatigue are common. Another classic association is migratory thrombophlebitis (Trousseau sign). Diagnosis is established with either ultrasound (less expensive) in patients with jaundice (head tumors) or CT scan (highly sensitive) in patients without jaundice (body and tail tumors). (Choice A) A chronic subdural hematoma from trauma would be more likely in an elderly person and typically presents with headache, personality changes, seizures, confusion, or hemiparesis. Abdominal pain and tenderness with anorexia and weight loss are not expected. Although neurogenic gastric mucosal injury (Cushing ulcer) can be associated with traumatic brain injury, this condition is characterized by acute onset, usually with prominent gastric bleeding and obvious neurologic impairment. (Choice B) Duodenal ulcers can also cause burning epigastric pain. However, the pain is typically periodic and relieved by food, as it is generally a result of acid secretion in the absence of a food buffer. Anorexia and weight loss are less common. Antisecretory therapy with proton pump inhibitors or H2 receptor antagonists generally provides some relief. This patient describes constant pain accompanied by anorexia, weight loss, and systemic symptoms, red flags that should raise suspicion for a malignancy. (Choice C) A major depressive episode could be responsible for fatigue, anorexia, and weight loss, but abdominal pain and tenderness would not be typical. Even if a primary mood disorder is suspected, localized pain with weight loss usually warrants evaluation for occult malignancy. (Choice E) Post-traumatic stress disorder (PTSD) consists of persistent reexperiencing of a previous traumatic event with recurrent attacks of anxiety, hyperarousal, nightmares, and/or flashbacks. This patient may have experienced a stressful event during his criminal investigation, but he does not describe recurrent distressing memories or nightmares related to the event. In addition, PTSD disturbs social and occupational functioning but does not typically cause anorexia, weight loss, or signs of organic disease such as abdominal pain and tenderness. Educational objective: Pancreatic cancer classically presents insidiously with a combination of constant and gnawing epigastric pain that is frequently worse at night, anorexia with weight loss, and jaundice due to extrahepatic biliary obstruction. A peptic duodenal ulcer typically causes periodic epigastric pain relieved by meals. References: Pancreatic cancer: diagnosis and management. (http://www.ncbi.nlm.nih.gov/pubmed/16477897)

A 54-Year-Old Man Comes to the Physician Complaining of Fatigue