A 65-year-old woman comes to the office due to 4 weeks of progressive abdominal pain that is constant and worse with eating. It has caused her to eat less often, and she has noticed some weight loss. The patient has had several years of heartburn, which is relieved by over-the-counter medications. She has taken omeprazole for the last 4 weeks, but it has not improved the pain. The patient has a 10-pack-year smoking history but quit several years ago. She does not use alcohol. Vital signs are within normal limits. BMI is 34 kg/m². Abdominal examination shows epigastric tenderness. Stool occult blood testing is negative. Complete blood count, liver studies, and serum chemistry are normal. Upper gastrointestinal endoscopy is performed and reveals mild esophagitis but no gastritis. Abdominal ultrasound shows 2 large gallstones with no gallbladder wall thickening or pericholecystic fluid, and there is no ductal dilatation. The pancreas is poorly visualized due to overlying gas. Which of the following is the most appropriate next step in management of this patient?

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This patient has had 4 weeks of constant, progressive epigastric pain that is worse with eating. Basic laboratory evaluation, ultrasound of the biliary tree, and esophagogastroduodenoscopy are unrevealing (mild esophagitis and large gallstones with no gallbladder inflammation/ductal dilation are unlikely to cause weeks of persistent pain). Because the pancreas has not been adequately visualized, the best next step is to perform a CT scan of the abdomen to examine the pancreas for a mass or inflammation. Pancreatic cancer is common in those with a history of smoking or alcohol abuse. It most often presents with epigastric pain that is progressive and constant and often radiates to the flanks or the back. The pain is typically worse with eating and lying supine and improved by lying in a curled position. Weight loss, jaundice, and nausea also commonly occur. Diagnostic work-up begins with CT scan of the abdomen, which has high sensitivity and is far better than ultrasound for detecting small (<3 cm) tumors. (Choice B) Endoscopic retrograde cholangiopancreatography is primarily used for suspected choledocholithiasis, which generally causes abdominal pain, nausea/vomiting, and laboratory abnormalities (eg, elevated transaminases, bilirubin, and alkaline phosphatase). This patient with normal laboratory studies and no common bile duct dilation is unlikely to have choledocholithiasis. (Choices C and D) HIDA scan is primarily used to exclude cholecystitis in patients with suggestive symptoms (eg, severe right upper quadrant pain, fever, tachycardia, leukocytosis with left shift) but no gallbladder inflammation or biliary obstruction on ultrasound. This patient's constant midepigastric pain with normal laboratory studies is unlikely due to gallstone disease. Although laparoscopic cholecystectomy is generally recommended for those with biliary colic and acute cholecystitis, patients with asymptomatic gallstones do not need cholecystectomy. (Choice E) Mesenteric angiography can diagnose chronic mesenteric ischemia, which usually presents with severe pain with eating (intestinal angina) and food aversion. However, the pain is generally intermittent. In addition, the diagnosis is usually made with CT angiography (which is noninvasive) rather than mesenteric angiography (an invasive procedure). (Choice F) MR cholangiopancreatography is used to visualize the biliary and pancreatic ducts and is often obtained in those with suspected biliary obstruction or cholangiocarcinoma. This patient with epigastric pain has normal liver studies and a normal biliary tree on ultrasound, making these diagnoses less likely. Educational objective: The most common symptom of pancreatic cancer is insidious, continuous midepigastric pain that often radiates to the flanks or back and is sometimes worse with eating and lying down. CT scan of the abdomen is the first-line test for suspected pancreatic cancer.

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