The physician’s assistant I was working with in the emergency department had gone to see a patient for a complaint of itching and told me that that something didn’t feel right. Brian had been having issues with itching for the past several weeks and neither Benadryl nor a steroid prescription from his family doctor had helped. He had a bad reaction to poison ivy in the past and figured he had come into contact with it again, even though he hadn’t done any recent yard work.
Brian said he had been feeling a bit fatigued over the past few weeks and had been taking naps, which was unusual for him. He said his appetite was good, but once he started eating he would feel full much sooner than ever before. He thought maybe his stomach wasn’t right from the medications he was taking. His wife told him he needed to come to the emergency department to be evaluated.
My physician assistant (PA) ordered labs and a CT scan of Brian’s abdomen because she had noticed a slight yellowing of his skin and eyes. Brian’s wife had not noticed his yellow skin until the PA asked her if his skin looked normal to her. He had some marks from scratching but there was no rash to explain his itching. His abdomen was soft and there were no areas that were tender to the touch.
I went in to see Brian and had the same concerning feeling as my PA. I was hoping that our suspicions were incorrect. Brian’s wife was clearly anxious about what we would find. I explained that we were waiting on his labs and CT scan and that I would be back once we had some results to discuss.
We ordered the CT scan of his abdomen to help determine why he was jaundiced. Normally the liver releases bile (which contains bilirubin) through the common bile duct into the intestines, where it helps with digestion by breaking down fat. When the common bile duct is blocked, bile cannot get to the intestines and subsequently bilirubin builds up in the body. This can cause itching, which was Brian’s first symptom.
After seeing a few more patients, I got a call from the lab. His liver tests were abnormal, including an elevated bilirubin level, which explained the yellowing of his skin. I got a phone call from the radiologist a short time later saying Brian had a mass in the head of his pancreas, right next to his liver, that was highly concerning for pancreatic cancer. The mass was pressing against the common bile duct, which explained why his bilirubin levels were high.
Pancreatic cancer is hard to detect in its early stages when it is most curable, as it often doesn’t cause symptoms until it has spread to other organs. The radiologist didn’t see any evidence of spread to his liver or other organs, so I was hopeful we had caught it early in Brian’s case and that he would have a good outcome with available treatments.
There are several modifiable risk factors for pancreatic cancer, which include smoking, obesity, diabetes, exposure to certain chemicals, and chronic pancreatitis, which is inflammation of the pancreas. Other risk factors that can’t be changed include age, family history, gender, race and some inherited genetic conditions. There is ongoing research into other possible risk factors including diet, alcohol use, even lack of physical activity. Brian was a healthy guy who had only smoked for a few years when he was much younger. He didn’t know of any other family members with a history of pancreatic cancer and didn’t have any glaring risk factors for developing pancreatic cancer.
I sat with Brian and his wife to discuss his results. His wife had tears in her eyes when I walked in. Before I could even start talking, she said she knew there was something seriously wrong with her husband. Brian was quiet and did not say much as I went over everything, but he asked me if this was a death sentence. While I could not give him exact numbers, I explained that I was hopeful the odds were in his favor since there was no evidence of spread of the cancer. I also explained that there are new treatments on the horizon with ongoing research.
I admitted Brian to the hospital so that he could meet with the oncologist and surgeon to confirm his diagnosis and determine the best treatment plan, which would likely involve surgery and chemotherapy. He needed to undergo further testing to determine what treatment plan would offer him the best success. I shook Brian’s hand and hugged his wife when I left the room and assured them they were in good hands and that we would do everything we could to help him.
Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.firstname.lastname@example.org