Test your diagnostic skills with the following endoscopic quiz.
A 72-year-old man is referred for evaluation of abnormal liver chemistries. He has a history of unresectable pancreatic cancer (adenocarcinoma of the head). He originally presented with painless jaundice 16 months ago and was managed by placement of an endoscopic stent with subsequent chemotherapy after his liver chemistries normalized. Recently, he has noted mild nausea, anorexia, and occasional epigastric discomfort. He denies any fever, recurrent jaundice, dark urine, or change in bowel habit.
Past medical history is positive for controlled hypertension and stable arteriosclerotic heart disease on chronic medical therapy. He does not smoke or consume alcohol. His surgical history is significant for exploratory laparotomy, which demonstrated positive lymph nodes precluding resection of the pancreatic tumor.
Laboratory evaluation revealed normal CBC and three times normal elevation of the alkaline phosphatase level with mild elevations of the AST, ALT, and bilirubin levels.
Abdominal CT scan reveals mild dilatation of the biliary tree and several hypodensities in the liver "too small to characterize."
1) The most likely explanations for the patient's abnormal labs and symptoms include:
a) Liver metastasis
b) Medication reaction
c) Chemotherapeutic effect
d) Stent occlusion
2) The most appropriate management choice is:
a) Endoscopic ultrasound
b) PET scan
3) The photographs demonstrate:
a) Duodenal invasion
b) Duodenal ulcer
c) Occlusion of stent with debris
d) Occlusion of stent with tumor