Dr. Erika Kube
The physician assistant I worked with in the emergency department had gone to see a patient with a complaint of itching and told me something was wrong. Brian had been having issues with itching for several weeks and neither Benadryl nor a prescription for steroids from his family doctor had helped. He had a bad reaction to poison ivy in the past and thought 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 tired 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. He thought maybe his stomach was not well because of the medication he was taking. His wife told him he had to go to the emergency room to be evaluated.
My medical assistant (PA) ordered labs and a CT scan of Brian’s abdomen because she noticed a slight yellowing of his skin and eyes. Brian’s wife hadn’t noticed his yellow skin until the AP asked her if his skin looked normal. He had a few scratch marks but there was no rash to explain his itching. Her abdomen was soft and there were no tender areas.
I went to see Brian and got the same ominous feeling as my PA. I hoped our suspicions were wrong. Brian’s wife was clearly worried about what we were going to find. I explained that we were waiting for his labs and scanner and that I would come back once we had results to discuss.
We ordered the CT scan of his abdomen to help determine why he had jaundice. Normally, the liver releases bile (which contains bilirubin) through the common bile duct into the intestines, where it aids digestion by breaking down fats. When the common bile duct is blocked, bile cannot reach the intestines and subsequently bilirubin builds up in the body. It can cause itching, which was Brian’s first symptom.
After seeing a few other 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 received a phone call from the radiologist shortly afterwards saying that Brian had a mass in the head of his pancreas, right next to his liver, which was very concerning for pancreatic cancer. The mass was pressing against the common bile duct, which explained why his bilirubin levels were high.
Pancreatic cancer is difficult to detect in its early stages, when it is most curable, because it often does not cause symptoms until it has spread to other organs. The radiologist saw no evidence of spread to his liver or other organs, so I hoped we caught it early in Brian’s case and that he would have a good outcome with the treatments available.
There are several modifiable risk factors for pancreatic cancer, including smoking, obesity, diabetes, exposure to certain chemicals, and chronic pancreatitis, which is inflammation of the pancreas. Other risk factors that cannot be changed include age, family history, gender, race, and certain inherited genetic conditions. Research is ongoing on other possible risk factors, including diet, alcohol consumption, and 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 any other family members with a history of pancreatic cancer and had no obvious risk factors for developing pancreatic cancer.
I sat down 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 something was seriously wrong with her husband. Brian was quiet and didn’t say much as I went over everything, but he asked me if this was a death sentence. Although I couldn’t give him exact numbers, I explained that I was hopeful the odds were in his favor since there was no evidence of the cancer spreading. I also explained that there are new treatments on the horizon with ongoing research.
I admitted Brian to the hospital so 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 which treatment plan would offer him the best success. I shook Brian’s hand and kissed his wife as I left the room and assured them they were in good hands and that we would do everything we could to help.
Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.firstname.lastname@example.org
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