A 62-year-old man comes to the office due to anorexia, fatigue, and a 9 kg (20 lb) weight loss over the past 6 months. He rarely drinks alcohol and does not use illicit drugs, although he has smoked one pack of cigarettes daily for the past 40 years. The patient has previously been diagnosed with hypertension, diverticulosis, external hemorrhoids, and osteoarthritis. Current medications are atenolol and aspirin, and he has no known drug allergies. Temperature is 37 C (98.6 F), blood pressure is 132/88 mm Hg, pulse is 70/min, and respirations are 12/min. Physical examination reveals a soft abdomen that is mildly tender to deep palpation in the midepigastric region. The sclerae are icteric, and the skin is jaundiced. Laboratory results show: Antimitochondrial antibodies are negative. Abdominal ultrasound demonstrates mild dilation of the common bile duct; there are no stones present in the gallbladder and no evidence of gallbladder wall thickening. Which of the following is the best next step in the management of this patient's condition?

Question

A 62-year-old man comes to the office due to anorexia, fatigue, and a 9 kg (20 lb) weight loss over the past 6 months.  He rarely drinks alcohol and does not use illicit drugs, although he has smoked one pack of cigarettes daily for the past 40 years.  The patient has previously been diagnosed with hypertension, diverticulosis, external hemorrhoids, and osteoarthritis.  Current medications are atenolol and aspirin, and he has no known drug allergies.  Temperature is 37 C (98.6 F), blood pressure is 132/88 mm Hg, pulse is 70/min, and respirations are 12/min.  Physical examination reveals a soft abdomen that is mildly tender to deep palpation in the midepigastric region.  The sclerae are icteric, and the skin is jaundiced.  Laboratory results show:  Antimitochondrial antibodies are negative.  Abdominal ultrasound demonstrates mild dilation of the common bile duct; there are no stones present in the gallbladder and no evidence of gallbladder wall thickening.  Which of the following is the best next step in the management of this patient's condition?

Quizplus · Accepted Answer

11ec25c8_d81d_7a4b_bc81_1374f02ee955_MD0003_00 This patient with a history of tobacco use now has weight loss, fatigue, anorexia, and painless jaundice with dilation of the common bile duct on ultrasound. This presentation is concerning for pancreatic cancer, the 4th leading cause of cancer death in the United States. The presentation of pancreatic cancer varies with tumor location. Tumors in the pancreatic head often cause compression of the pancreatic duct and common bile duct, resulting in painless obstructive jaundice with elevations in serum bilirubin and alkaline phosphatase. Tumors in the pancreatic body or tail often result in progressive abdominal pain without jaundice. Abdominal ultrasound is usually the initial imaging performed on patients with jaundice. When the ultrasound is nondiagnostic (as in this case) or when there is clinical suspicion for pancreatic cancer in a nonjaundiced patient, an abdominal CT scan should be obtained. This imaging modality has a sensitivity of up to 97% in the detection of pancreatic cancer and can be used for staging purposes and preoperative planning. (Choice B) Endoscopic retrograde pancreatography is used to visualize the biliary tree and pancreatic ducts and allows for tissue sampling. However, it is invasive and has a lower sensitivity than CT scan for tumors located in the uncinate process or tail of the pancreas. It is typically recommended for patients in which other modalities were inconclusive and can sometimes be used to relieve obstruction (eg, via biliary stent placement). (Choice C) Percutaneous transhepatic cholangiogram is an invasive procedure used to evaluate the biliary tree of patients who have had a less invasive imaging fail. It can be used for stent placement across malignant obstructions but is not a first-line diagnostic technique. (Choice D) Serum amylase and lipase are elevated in pancreatitis, which typically presents with severe abdominal pain radiating into the back with nausea and vomiting, not painless jaundice. They are not helpful in diagnosing pancreatic malignancy. (Choice E) Serum CA 19-9 is a tumor marker that is often elevated in pancreatic cancer, but sensitivity is related to tumor size and is limited in small cancers. In addition, it has low specificity and may be elevated in multiple conditions (eg, hepatocellular cancer, cholangitis). It can be used to monitor disease progression but is less useful for diagnosis than CT scan. Educational objective: The presentation of pancreatic cancer is dependent on tumor location; tumors in the pancreatic head often present with painless obstructive jaundice, whereas those in the body or tail often cause abdominal pain without jaundice. Although ultrasound is the imaging test of choice to evaluate a jaundiced patient, a CT scan of the abdomen is indicated for those with a nondiagnostic ultrasound or to evaluate for suspected malignancy in a nonjaundiced patient. References: Diagnosis and detection of pancreatic cancer. (http://www.ncbi.nlm.nih.gov/pubmed/29189329)

A 62-Year-Old Man Comes to the Office Due to Anorexia