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:
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?
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.
