to the emergency department (ED) with a
4-month history of progressively worsening abdominal discomfort and fatigue. He has also
noticed darkening of his urine and slight yellow
discoloration of his eyes. His weight measured
5 months ago in his primary care physician’s
office was 91 kg (200 lb, BMI 29. 5) and in the
ED is 75 kg (165 lb, BMI 24. 4). He has noticed
bulky, malodorous, oily stools for about 2
months. Preliminary laboratory studies reveal
elevated levels of total bilirubin ( 2. 7 mg/dL)
and alkaline phosphatase (204 IU/L). Transab-dominal ultrasound (US) is obtained and reveals
a 3-cm pancreatic mass with biliary tract dilation.
•;Does;this;patient;have;pancreatic;cancer?
CLINICAL SIGNS AND SYMPTOMS
Establishing the diagnosis of pancreatic can-
cer in a patient who presents with a high index
of suspicion is critical. Patients with pancreatic
cancer usually present after a period of nonspe-
cific and vague symptoms, which typically are
experienced as abdominal discomfort, weight
loss, and weakness. It is estimated that approxi-
mately 25% of patients may complain of vague
abdominal pain up to 6 months prior to diag-
nosis. Up to 15% of patients may seek medical
attention more than 6 months prior to estab-
lishing a diagnosis of PDA. 34 The most com-
mon symptoms associated with pancreatic can-
cer in order of decreasing reported frequency
are weight loss, anorexia, abdominal/epigastric
pain, dark-colored urine, jaundice, nausea, back
pain, and diarrhea with associated steatorrhea. 35
Upwards of 15% of patients present with pain-
less jaundice, a term that is often associated with
pancreatic cancer. 36 On exam these patients
may have scleral icterus, sublingual jaundice,
epigastric pain on palpation, weight loss, hepa-
tomegaly, lymphadenopathy and a nontender,
distended, palpable gallbladder (also known as
Courvoisier sign). 34 Abdominal signs and symp-
toms arise from tumor growth into surrounding
vessels, tissues, and ducts within the abdomi-
nal cavity. Compression of the common bile
duct accounts for the development of jaundice.
Tumor growth around the stomach and duode-
num can lead to delayed gastric emptying and
subsequently nausea and vomiting. Constric-
tion of the pancreatic duct leads to pancreatic
insufficiency, precipitation of weight loss, and
steatorrhea. Pancreatic insufficiency can worsen
abdominal pain, and lead to increased weight
loss and flatulence.
Less common symptoms include pain, erythema, and edema involving the lower extremities,
which may be reflective of migratory thrombophlebitis (commonly known as Trousseau syndrome). Thromboembolic disease, including
pulmonary embolism, portal vein, and deep
vein thromboses are frequently encountered
complications of pancreatic cancer. The incidence of thromboembolic events in patients
with PDA has been reported to be as high as
54%. 37 Of all signs encountered, weight loss is
the most common and most profound. Patients
with advanced PDA have severe degrees of cachexia. Some patients present with as much as a
5 kg/m2 decrease in their BMI from pre-illness
baseline BMI, and lose another 3 to 4 kg/m2
through disease progression. 38 At the time of
diagnosis, many patients have already undergone significant weight loss, which can have
substantial implications on treatment planning
and clinical outcomes.
•;What;other;studies;can;be;done;to;assist;in
making the diagnosis?
LABORATORY ABNORMALITIES AND TUMOR MARKERS
Elevations in alkaline phosphatase,
γ-glutamyltransferase (GGT), serum aspartate
aminotransferase (AST), serum alanine aminotransferase (ALT), and direct fractions of
bilirubin are common in patients with PDA.
Patients will usually have an obstructive pattern
on their liver panel, with predominant elevations in direct bilirubin, alkaline phosphatase,
and GGT, as compared with AST and ALT.
Other baseline laboratory studies, including
