A 50-year-old Jewish man comes to the clinic because of back pain that has been worsening for about a week. He says that he has recently noticed small, painful bumps around his body and slight ankle swelling, but these symptoms come and go and do not bother him much. He does not smoke or use illicit drugs, and says he has “a few drinks sometimes on weekends with his friends.” Which of the following is the most likely location of the cause of this patient's symptoms?
- Antrum of the stomach
- Centrilobular region of the liver
- Extrahepatic bile ducts
- Fundus of the gallbladder
- Head of pancreas
Head of pancreas
Pancreatic carcinoma is most commonly found in the head of the pancreas and presents with pain that radiates to the back between the shoulder blades, migratory thrombophlebitis, and general malaise and typically presents in older Jewish and African males. Other major risk factors include smoking, diabetes, and chronic pancreatitis.
A 55-year-old man comes to the office because of yellowing of his skin and abdominal pain. Ultrasonography demonstrates a 5 cm (2 in) mass in the head of the pancreas. Endoscopic retrograde cholangiopancreatography with sampling shows cells with large, hyperchromatic nuclei, and a high nuclear-to-cytoplasmic ratio. Chromogranin A staining is negative. Which of the following histological features is most likely to be found in the tumor biopsy?
- Acinar dysplasia with cellular infiltrates
- Ballooning degeneration with Mallory bodies
- Disorganized glandular structure with perineural invasion
- Islet cells hyperplasia with prominent rossettes
- Fat saponification and necrosis
Disorganized glandular structure with perineural invasion
Pancreatic ductal adenocarcinoma is the most common type of pancreatic malignancy. It derives from ductal epithelia and is characterized histologically by disorganized glandular structure with mucin production and perineural invasion.
A 55-year-old man comes to the office because of yellowing of his skin. His conjugated bilirubin and alkaline phosphatase concentrations are elevated. Contrast-enhanced CT scan of the abdomen is obtained and shows a well-circumscribed mass in the head of the pancreas with no signs of metastatic disease. Which of the following is the most appropriate next step in management?
- Biopsy of the mass
- Esophagogastroduodenoscopy (EGD)
- Magnetic resonance cholangiopancreatography (MRCP)
- Non contrast CT
- Surgical resection
Pancreatic cancer of the head of the pancreasshould undergo resection, and does not require prior biopsy if abdominal CT staging shows no signs of metastatic disease.
A 60-year-old man comes to the emergency department because of weight loss, abdominal pain, fatigue, and loss of appetite. The patient does not report any symptoms of nausea, vomiting, or diarrhea. Physical examination shows jaundice and a non-tender palpable gallbladder. He has not noticed blood in his stool. His temperature is 37ºC (98.6ºF), pulse is 75/min, respirations are 20/min, and blood pressure 120/75 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 100%. Which of the following is the most significant risk factor for this patient's diagnosis?
- Alcohol use
- Inflammatory bowel disease
- Pickled vegetables
- Vitamin E deficiency
Environmental risk factors for pancreatic adenocarcinoma include cigarette smoking, diabetes, insulin resistance, hereditary forms of pancreatitis, chronic pancreatitis, and a history of gastrectomy or cholecystectomy. Cessation of smokingprovides a significant decrease in risk for pancreatic adenocarcinoma.
A 71-year-old woman comes to the office because her friends have noticed a slight yellowing of her skin over the past month. She says she has persistent "itching all over", had a recent weight loss of 6.8-kg (15-lb), and has a mild pain in the middle of her back after she eats a meal. On physical exam, there is round cystic mass in the upper abdomenthat is non-tender to palpation. Which of the following specific serum markers is most likely to be abnormally elevated?
- CA 19-9
- CA 125
CA 19-9 is a tumor marker for exocrine pancreatic cancer, which can be suspected when a patient is characterized by jaundice and an enlarged, non-tender gall bladder.
A 55-year-old man comes to the office because of upper back pain for a month. He has lost 18-kg (40-lb) over the last 3 months. He has a history of hypertension and chronic lower back pain secondary to a construction accident 20 years prior. His current medications include lisinopril and hydrocodone. Physical examination shows scleral icterus. Laboratory analysis shows elevated carcinoembryonic antigen and CA 19-9. A CT scan is obtained and shows a mass contained in the head of the pancreas. The patient is referred to a surgeon for a Whipple procedure. Which of the following organs are removed in this procedure?
A) Entire pancreas, common bile duct, stomach, duodenum, jejunum, and appendix
B) Entire pancreas, gall bladder, proximal ileum, and left hepatic lobe
C) Head of the pancreas, duodenum, proximal jejunum, gall bladder, common bile duct, and distal stomach
D) Head of the pancreas, gall bladder, and common bile duct
E) Head of the pancreas, proximal jejunum, duodenum, and common bile duct
Head of the pancreas, duodenum, proximal jejunum, gall bladder, common bile duct, and distal stomach
The Whipple procedure is the removal of the head of the pancreas, duodenum, proximal jejunum, gall bladder, common bile duct, and distal stomach.
A 63-year-old man presents at an office visit complaining of occasional dull epigastric pain. Physical examination shows mild jaundice and his gall bladder is palpable and non-tender. He has the following laboratory results:
- Billiary obstruction
- Dubin-Johnson syndrome
- Gilbert syndrome
- Hemolytic anemia
- Non-alcoholic fatty liver disease
Obstructive jaundice causes conjugatedhyperbilirubinema and elevated liver enzymes; patients present with a palpable, non-tender gallbladder, which should raise suspicion of a pancreatic tumor.
A 64-year-old man comes to his oncologist because of severe abdominal pain from his metastatic pancreatic adenocarcinoma. He was diagnosed a month ago and is currently using transdermal fentanylpatches. He is considering undergoing a procedure for adjunctive pain relief during which local anesthesia will be injected to block nociception from abdominal organs. Which of the following is the most likely side effect of this procedure?
A celiac plexus block is a palliative procedure to reduce abdominal pain experienced by patients with pancreatic cancer. Because sympatheticactivity to abdominal organs is severed, the parasympathetic nervous system takes over, resulting in effects such as diarrhea.