A 60-year-old man presents to the clinic with a three-month history of progressive jaundice, dark urine, and weight loss. He also reports generalized itching. Past medical history is unremarkable, and he does not take any medications. He has a 20-pack-year smoking history but quit 10 years ago. Vital signs are within normal limits. Physical examination reveals scleral icterus and a palpable non-tender gallbladder.
Laboratory results are as follows:
Albumin: 3.5 g/dL
Total bilirubin: 12.0 mg/dL
Direct bilirubin: 9.8 mg/dL
Alkaline phosphatase: 950 U/L
Aspartate aminotransferase (AST): 65 U/L
Alanine aminotransferase (ALT): 60 U/L
Abdominal ultrasound shows a dilated common bile duct but no gallstones. The gallbladder is enlarged. Which of the following is the most appropriate next step in management?
The correct answer is:
B) Computed tomography (CT) scan of the abdomen
This patient presents with painless jaundice, weight loss, and a palpable and enlarged gallbladder (Courvoisier sign), which are classic signs of pancreatic cancer, particularly of the head of the pancreas. A CT scan of the abdomen is the most appropriate initial next step to evaluate for pancreatic cancer and assess the extent of any mass and possible local metastasis.
Answer choice A: Anti-mitochondrial antibody (AMA) titer, is incorrect. The AMA is used to diagnose primary biliary cholangitis, which does not fit the patient’s presentation.
Answer choice C: ERCP, is incorrect. ERCP is useful for diagnosing and managing biliary obstruction but is generally not the first diagnostic step for a suspected pancreatic mass. It is also more expensive than ultrasound or CT, and as an invasive procedure, it is associated with complications such as pancreatitis, bleeding, and cholangitis.
Answer choice D: Liver biopsy, is incorrect. Liver biopsy is not indicated as the initial diagnostic step in suspected pancreatic cancer; imaging studies are preferred for initial evaluation and diagnosis.
Answer choice E: Serum alpha-fetoprotein level, is incorrect. Serum alpha-fetoprotein level is used to screen for hepatocellular carcinoma, not pancreatic cancer.
Key Learning Point
In a patient with painless jaundice, weight loss, and an enlarged and palpable gallbladder, a CT scan of the abdomen is the most appropriate next step to evaluate for pancreatic cancer, as it provides detailed imaging to identify a pancreatic mass and assess for local metastatic disease.
