Practice Questions
A 68-year-old man with a history hypertension and osteoarthritis presents to the office for an annual physical exam. He reports no concerns. He has a 30-pack-year smoking history and does not drink alcohol or use recreational drugs. Physical examination reveals a non-distended abdomen with no tenderness to palpation in the epigastric region. The skin is jaundiced and the sclerae are icteric. CT scan of the abdomen and pelvis reveals diffuse pancreatic ductal dilation with dilation of the common bile duct and intrahepatic ductal dilation with a mass at the pancreatic head.
A 68-year-old man with hypertension and osteoarthritis presents to the office due to decreased appetite and a 15-pound weight loss over the past 5 months. He also reports feeling fatigued over the past 3 months. He has a 30-pack-year smoking history and does not drink alcohol or use recreational drugs. Physical examination reveals a nondistended abdomen with mild tenderness to palpation in the epigastric region. The skin is jaundiced and the sclerae are icteric. Laboratory findings are notable for a total bilirubin of 6.2 mg/dL, direct bilirubin 4.8 mg/dL, indirect bilirubin 1.4 mg/dL, alkaline phosphatase of 586, AST of 103, ALT of 96. Abdominal ultrasound reveals mild dilation of the common bile duct with no stones or gallbladder wall thickening.
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Question 2 Answer:
This patient’s presentation of weight loss, anorexia, fatigue, and painless jaundice with common bile duct dilation on ultrasound is most concerning for pancreatic cancer. In this case, a tumor in the pancreatic head is most likely due to physical examination and laboratory results (elevated bilirubin and alkaline phosphatase) consistent with obstructive jaundice. Given a nondiagnostic abdominal ultrasound with continued suspicion of a pancreatic malignancy, the next best step in management is (C) CT abdomen and pelvis. CT abdomen and pelvis is a noninvasive imaging option that is highly sensitive for pancreatic tumors and can be helpful for cancer staging and preoperative planning. In addition to a CT scan, an MRI and possibly an EGD/EUS and/or biopsy could be warranted as future diagnostic steps. (A) Serum CA 19-9 is a tumor marker for pancreatic cancer that can be used to monitor disease progression but is less useful for diagnosis than CT scan. (B) ERCP is also used to visualize the biliary tree but is invasive and less sensitive than CT scan for pancreatic tumors located outside of the head of the pancreas. (D) Start neoadjuvant chemotherapy would be premature in this patient without first confirming a diagnosis of pancreatic cancer.
Question 1 Answer:
This patient’s presentation of painless jaundice with a pancreatic mass and dilation of the pancreatic, common, and intrahepatic bile ducts on CT scan is most concerning for pancreatic cancer. In this case, a tumor in the pancreatic head is most likely causing biliary obstruction, which can cause physical examination findings of painless jaundice due to direct hyperbilirubinemia. Therefore, the set of laboratory findings that would be consistent with direct hyperbilirubinemia and be expected in this patient is (A). (B) is consistent with indirect hyperbilirubinemia, which would not be expected in this case of biliary obstruction. (C) demonstrates elevated aminotransferases, which could be due to acute hepatitis and/or certain medications among other possibilities, but would not be expected in this case of biliary obstruction. (D) is a set of normal laboratory findings that would be unexpected in this patient with jaundice and biliary obstruction.