A Patient with Pancreatic Cancer Presents with 30-lb Weight Loss over 3 Months

An 83-yo AAM with a negative PMH came to the outpatient clinic with CC: weight loss of 30 lbs for 3 months and weakness.

He was not on any medications. His appetite was good but he continued to loose weight, he denied depression and any other symptoms apart from lower abdominal pain and constipation.

Physical examination:
Vitals: WNL
Abdomen: Mild suprapubic tenderness
Rectal exam: mildly enlarged prostate

What are you thinking about in terms of DDx?
CA, Infection, Depression


Laboratory results

Initial CBC: Mild anemia – mixed picture of ACD and IDA
Initial CMP: WNL
PSA 6.8
UA: suggestive of UTI
CXR: WNL

What would you do next?
The UTI was treated with Levaquin. Constipation resolved after patient took Castor oil PRN. But weight loss continued.

What happened?
He was scheduled for a colonoscopy and a CT of the abdomen and pelvis was ordered.

What happened next?
The CT scan of the abdomen showed an ill-defined density in the pancreatic head. A follow-up CT scan with pancreatic protocol showed a mass suspicious for pancreatic cancer and a low-density lesion in the liver.


An ill-defined mass around the pancreatic head and a dilated pancreatic duct.


A hypodense liver lesion.


The report of CT scan of abdomen and pelvis.

The patient developed diarrhea and was admitted for treatment of dehydration. A colonoscopy showed a normal colon. IVF and Pancrease TID were started.

The patient refused a CT-guided biopsy of the pancreas and was discharged home after a 3-day hospital stay in stable condition. He expired 4 months later under hospice care.

Final diagnosis:
Pancreatic cancer.

What did we learn from this case?
Think about imaging studies, e.g. CT scan of the abdomen early.
Respect patient's wishes regarding goals of care and end-of-life care.

References:
Pancreatic Cancer: Diagnosis and Management. AFP 2/06

Further reading:
Pancreatic neoplasm. Unbounded Medicine, 2007.
In the Former First Family of Jimmy Carter, Cancer Has a Grim Legacy. The New York Times, 08/2007.
Pavarotti out of hospital. USA Today, 08/2007.

Published: 03/11/2005
Updated: 08/25/2007