A 65-year-old man comes to the office due to 4 months of abdominal pain, nausea, and occasional emesis. The pain is deep, mid-epigastric, persistent, and non-radiating. There is no consistent relationship between the pain and food intake. He has no difficulty swallowing, hematemesis, black stools, blood in the stool, or diarrhea. The patient thinks he may have lost weight recently. He emigrated to the United States from China 20 years ago but frequently travels to China to visit family. He has no significant medical or surgical history. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.9 C (98.4 F), blood pressure is 110/78 mm Hg, pulse is 78/min, and respirations are 16/min. BMI is 20 kg/m². Heart and lung sounds are normal. The upper abdomen is mildly tender to palpation but nondistended. Hepatomegaly is present. Bowel sounds are normoactive. Laboratory results are as follows: Laboratory testing last year was normal. Which of the following is most likely causing this patient's symptoms?

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This patient's persistent mid-epigastric abdominal pain, nausea/vomiting, weight loss, and microcytic anemia (likely iron deficiency) raises concern for gastric cancer. Risk is greatest in those from Eastern Asia (eg, China), Eastern Europe, and the Andean portion of South America due to diets rich in salt-preserved food and nitroso compounds, which promote gastric injury and carcinogenesis. Helicobacter pylori infection, pernicious anemia, and smoking also increase risk. Most cases present late in the disease course when tumors have grown large enough to cause progressive epigastric abdominal pain, weight loss due to early satiety, and dysphagia or nausea/vomiting due to proximal stomach obstruction. Because friable tumor vessels often ooze blood into the gastric lumen, many patients develop iron deficiency anemia without overt signs of gastrointestinal bleeding ("slow bleed"). Metastases to the liver can also cause hepatomegaly, elevated alkaline phosphatase/transaminases, and signs of liver failure (eg, hypoalbuminemia). Workup generally begins with esophagogastroduodenoscopy to visualize the stomach and to biopsy suspicious lesions. Staging imaging (eg, CT abdomen) is then usually required to evaluate for metastatic disease. (Choice A) Chronic pancreatitis often causes epigastric pain and nausea/vomiting, but the pain usually radiates to the back and is worse after eating. Most cases arise in those who abuse alcohol or have structural abnormalities in the pancreas. Hepatomegaly and microcytic anemia are rare. (Choice B) Chronic viral hepatitis is endemic in Asia and often causes nausea, weight loss, and mild transaminitis. However, epigastric pain, emesis, and microcytic anemia are atypical. (Choice C) Duodenal ulcers often cause epigastric pain and nausea and vomiting (when they obstruct the gastric outlet). However, pain typically occurs 2-5 hours after a meal (when acid is secreted and no food is present to buffer its effects). Furthermore, hepatomegaly and elevated alkaline phosphatase/transaminases would be atypical. (Choice E) Hookworm infections often cause abdominal pain, nausea/vomiting, and microcytic anemia due to chronic gastrointestinal blood loss. However, hepatomegaly and elevated alkaline phosphatase/transaminases are uncommon. In addition, most cases are associated with peripheral eosinophilia (total peripheral eosinophils >7% or >500/mm³). (Choice F) Pancreatic cancer often presents with subacute epigastric pain that radiates to the flanks/back, weight loss, and nausea. Although pancreatic head tumors can obstruct biliary drainage and lead to elevated transaminases and alkaline phosphatase, most obstructions also cause hyperbilirubinemia and jaundice. Furthermore, microcytic (iron deficiency) anemia in an elderly patient is more likely due to colon or gastric cancer than to pancreatic cancer, which does not typically bleed into the gastrointestinal tract. Educational objective: Gastric cancer is common in those from Eastern Asia, Eastern Europe, and South America. It generally presents with progressive epigastric pain and weight loss. Friable tumor vessels can bleed into the stomach lumen, leading to iron deficiency anemia. Metastasis to the liver can result in hepatomegaly and elevated transaminases and alkaline phosphatase. References: Cancer of the stomach. A patient care study by the American College of Surgeons. (http://www.ncbi.nlm.nih.gov/pubmed/8239772) Cancer statistics in China, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26808342) Metastatic spread in patients with gastric cancer. (http://www.ncbi.nlm.nih.gov/pubmed/27447571)

A 65-Year-Old Man Comes to the Office Due to 4