A 69-year-old man presents to his primary care physician with progressive fatigue, early satiety, and an 18-pound unintentional weight loss over the past 6 months. His medical history is significant for chronic Helicobacter pylori infection that was treated 10 years ago, hypertension, and hyperlipidemia. Medications include lisinopril and atorvastatin. He has smoked one pack of cigarettes daily for 40 years. Temperature is 36.9°C (98.4°F), blood pressure is 128/74 mm Hg, pulse is 88/min, and respiratory rate is 14/min. Physical examination reveals mild epigastric tenderness and a palpable left supraclavicular lymph node. Laboratory studies demonstrate the following:
Hemoglobin: 9.2 g/dL
MCV: 71 μm³
Ferritin: 8 ng/mL
Which of the following is the most likely diagnosis?
The correct answer is:
A) Gastric adenocarcinoma
This patient has several classic features of gastric adenocarcinoma, including progressive weight loss, early satiety, iron deficiency anemia, and a palpable left supraclavicular lymph node (Virchow node). Early satiety suggests impaired gastric distensibility due to an infiltrating gastric mass, while iron deficiency anemia raises concern for chronic occult gastrointestinal blood loss. The presence of Virchow node enlargement reflects metastatic spread through the thoracic duct and is a classic board-style clue for gastric malignancy. His history of prior H. pylori infection and long-term tobacco use further increases his risk.
Gastric adenocarcinoma is the most common gastric malignancy worldwide. Chronic H. pylori infection causes chronic gastritis that may progress through intestinal metaplasia and dysplasia to carcinoma. Common presenting symptoms include weight loss, anorexia, early satiety, abdominal discomfort, and iron deficiency anemia. Diagnosis is established by upper endoscopy with biopsy. Once diagnosed, staging typically includes CT imaging and evaluation for metastatic disease. Prognosis is often poor because many patients present with advanced disease.
Answer choice B: Gastroesophageal reflux disease, is incorrect.
Students may select GERD because it is a common upper gastrointestinal disorder. However, GERD typically presents with heartburn and regurgitation rather than constitutional symptoms, iron deficiency anemia, or lymphadenopathy. GERD would not explain Virchow node enlargement or significant weight loss.
Answer choice C: Irritable bowel syndrome, is incorrect.
IBS commonly causes abdominal pain associated with altered bowel habits. However, IBS is a functional disorder and should not cause alarm findings such as anemia, weight loss, or metastatic lymphadenopathy. The presence of these features should always prompt evaluation for organic disease.
Answer choice D: Pancreatic pseudocyst, is incorrect.
A pancreatic pseudocyst usually develops several weeks after acute pancreatitis and presents with abdominal pain, nausea, or early satiety due to mass effect. It would not be expected to cause iron deficiency anemia or development of an enlarged Virchow node.
Answer choice E: Peptic ulcer disease, is incorrect.
Peptic ulcer disease may cause chronic blood loss and iron deficiency anemia, making it a tempting distractor. However, it does not adequately explain the profound weight loss, early satiety, and metastatic lymphadenopathy seen in this patient. These findings are much more concerning for gastric malignancy.
Key Learning Point
Alarm symptoms such as weight loss, iron deficiency anemia, early satiety, and Virchow node enlargement should prompt evaluation for gastric adenocarcinoma with upper endoscopy and biopsy.
