Review Question - QID 108391

Pancreatic adenocarcinoma most often occurs in the head of the pancreas and presents as obstructive jaundice; other signs and symptoms may include weight loss, postprandial epigastric pain, diarrhea, acholic stools, Courvoisier’s sign, Virchow’s node or Trousseau’s sign. Lab abnormalities include increased bilirubin, alkaline phosphatase, and CA 19-9.

Pancreatic cancer is the fourth leading cause of cancer-related death in the United States. Risk factors include family history, smoking, chronic pancreatitis, obesity, diabetes mellitus, and heavy alcohol use. Courvoisier’s sign refers to a right upper quadrant mass with painless jaundice. Virchow’s node is a left supraclavicular lymphadenopathy associated with advanced abdominal malignancies. Trousseau sign of malignancy (migratory thrombophlebitis) is characterized by recurrent, migratory thrombosis in superficial veins secondary to the hypercoagulable state caused by occult malignancies.

De La Cruz et al. discuss the diagnosis and management of pancreatic cancer. CT scan is used for diagnosis and staging of pancreatic cancer. For eligible patients, surgical resection is the only potentially curative treatment for pancreatic ductal carcinoma, although five year survival is still <20%. Postoperatively use of gemcitabine or fluorouracil/leucovorin as adjuvant chemotherapy improves survival by several months.

Scara et al. discuss CA 19-9 (known as carbohydrate antigen 19-9, cancer antigen 19-9 or sialylated Lewis antigen). It is commonly used as a serum tumor marker for pancreatic carcinoma in symptomatic patients and for monitoring therapy in patients with pancreatic adenocarcinoma. However, its poor positive predictive value (72.3%) does not make it a good cancer-specific marker screening tool.

Figure A demonstrates a distended gall bladder and biliary tree with a small 3 cm pancreatic head mass.

Incorrect Answers:
Answer 2: Cholelithiasis (gallstones) is often symptomatic but may lead to acute cholecystitis, obstruction of the bile ducts, ascending cholangitis, or pancreatitis. Murphy’s sign, a tender gallbladder in the right upper quadrant of the abdomen, is suggestive of cholecystitis.
Answer 3: Cholangiocarcinoma is a rare neoplasm of the bile ducts that also presents as obstructive jaundice. It is associated with primary sclerosing cholangitis (PSC), ulcerative colitis, and parasitic liver fluke infections.
Answer 4: Hepatic carcinoma is usually secondary to viral hepatitis infection or cirrhosis. Patients often present with jaundice and right upper quadrant pain.
Answer 5: Autoimmune hepatitis, associated with anti-smooth muscle auto-antibodies, can present with jaundice and right upper quadrant pain. It is more commonly associated with females 15-40 years old and those with systemic lupus erythematous (SLE).