Snapshot A 69-year-old man presents to the emergency department with generalized fatigue and abdominal pain. He has had a 20-pound weight loss over the course of 3 months. He has a past medical history of alcohol use disorder and longstanding diabetes. He also has been smoking 1 pack of cigarettes for the past 50 years. Physical examination is notable for scleral icterus and abdominal tenderness to palpation in the epigastric region. CT abdomen with and without contrast demonstrates a mass at the head of the pancreas. Introduction Overview malignancy affecting the pancreas types adenocarcinoma > 90% of pancreatic cancers are adenocarcinoma arising from the pancreatic ducts most tumors arise in the head of the pancreas (~75%) neuroendocrine Epidemiology incidence 4th leading cause of cancer in the United States demographics > 60 years of age risk factors smoking heavy alcohol consumption obesity chronic pancreatitis long standing diabetes Etiology likely from accumulation of various genetic mutations e.g., KRAS2 and CDKN2A Pathogenesis pancreatic adenocarcinoma begins in the pancreatic ductal epithelium premalignant lesions (e.g., pancreatic intraepithelial neoplasia) then progress to malignant lesions secondary to accumulation of genetic mutations Prognosis very poor prognosis Presentation Symptoms generalized fatigue abdominal pain sequela of biliary obstruction in tumors arising from the pancreatic head jaundice dark urine Physical exam unexplained weight loss hepatomegaly Courvoisier sign palpable gallbladder in pancreatic cancers involving the head of the pancreas Imaging Abdominal ultrasound indication initial imaging study in patients who present with jaundice has a high sensitivity (> 95%) in detecting a pancreatic mass Abdominal CT scan indication initial imaging study in patients who present with abdominal pain and weight loss but without jaundice confirms the presence of a pancreatic mass if it is found in the abdominal ultrasound Endoscopic retrograde cholangiopancreatography (ERCP) indication performed if abdominal ultrasound and abdominal CT scan do not demonstrate an obvious cause of biliary obstruction can obtain a tissue diagnosis for small tumors that cannot be appreciated on the above imaging modalities Endoscopic ultrasonography indication can be used to obtain a tissue diagnosis not always necessary if a resectable mass is demonstrated on abdominal CT scan Studies Serum labs CA 19-9 a tumor marker lipase AST, ALT, and alkaline phosphatase may be elevated if the malignancy compresses the biliary system Differential Acute pancreatitis differentiating factor no pancreatic mass seen Gastric cancer differentiating factor mass seen in the stomach Treatment Treatment depends on the stage of the pancreatic cancer Surgical Whipple procedure indication in resectable pancreatic cancer Complications Obstructive cholestasis Gastric outlet obstruction Diabetes Migratory thrombophlebitis
QUESTIONS 1 of 2 1 2 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M1.ON.13.66) A 70-year-old male visits his primary care physician because of progressive weight loss. He has a 20-year history of smoking 2 packs of cigarettes a day and was diagnosed with diabetes mellitus 6 years ago. After physical examination, the physician tells the patient he suspects adenocarcinoma at the head of the pancreas. Which of the following physical examination findings would support the diagnosis: Review Topic | Tested Concept QID: 101123 Type & Select Correct Answer 1 Lymphadenopathy of the umbilicus 0% (0/10) 2 Acanthosis nigricans 20% (2/10) 3 Palpable gallbladder 80% (8/10) 4 Renal artery bruits 0% (0/10) 5 Splenomegaly 0% (0/10) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3
All Videos (3) Podcasts (0) Login to View Community Videos Login to View Community Videos Pancreatic Treatment Oncology - Pancreatic Cancer 2/13/2015 21 views (1) Login to View Community Videos Login to View Community Videos Pancreatic Cancer: pathophysiology and diagnosis Oncology - Pancreatic Cancer 2/13/2015 36 views (1) Login to View Community Videos Login to View Community Videos Pancreatic cancer Oncology - Pancreatic Cancer 2/13/2015 19 views (0)