Neoplastic  Disorders – Group E
	Our 57 year old gentleman symptoms is concerning for a cancerous process.  His malaise, fatigue, depression and weight loss are the initial alerts. These initial complaints lead to an investigation of the presentation of pancreatic cancer. It is a hard cancer to diagnose because the symptoms can be related to other disease processes. The pancreas is a small, approximately 5 inches in length and is encircled by the liver, gallbladder, and small intestine.  It produces insulin for sugar metabolism and assists with neutralization of stomach acids and the breakdown of food.  Ninty-five percent of pancreatic cancers occur in the pancreatic ducts.  
	Pancreatic cancer is the fourth leading cancer in men and it rarely presents before age 50.  Our gentleman is 57 years of age.  His liver span, PT and PTT are within normal range which again moves one over to look at the pancreas.  A blood sugar level would be helpful to look for elevation.  Also concerning is his complaint of itching.  You can develop itching when you have a high level of bile acids that accumulate in the skin.  
	His physical symptoms of jaundice of the sclera and skin, light colored stools and itching can be caused by an obstruction of the bile duct. “The last portion of the bile duct joins with the pancreatic duct in the back of the head of the pancreas and empties into the duodenum. As a tumor grows in the head of the pancreas the bile duct becomes blocked.  When the duct becomes blocked (obstructed) bile backs up into the liver and enters the bloodstream. This leads to a visible yellowing of the eyes and the skin. As bile is not getting to the digestive tract, stool becomes light or clay-colored” (John’s Hopkins). Another reason to believe there is bile duct obstruction are the lab findings of the increased alkaline phosphatase, direct bilirubin, and elevated AST/ALT.
 	His liver enzymes and bilirubin are elevated.  The icterus of his sclera and skin, jaundice, is a result of the breakdown of blood cells which increases his bilirubin.  Although our patient is not experiencing nausea or vomiting, he has a loss of appetite and a 20 pound weight unintentional weight loss.  If a tumor blocks the upper portion of the intestinal track, specifically the duodenum, then he might experience nausea and vomiting.   Additionally, when enzymes are unable to be released into the intestinal track it is difficult to digest foods, contributing to weight loss and malnutrition.  Malnutrition contributes to the malaise, depression, and fatigue that he in experiencing.
	The cause of pancreatic cancer is unknown.  Smoking appears to be the clearest risk factor and our patient is a smoker. Other important information to note would be if the patient has any history of pancreatitis or family history of pancreatic cancer or pancreatitis which would put him at an increased risk. Interestingly, researchers at the University of Minnesota found the daily use of aspirin decreased the risk of pancreatic cancer.  This did not prove true for anti-inflammatories.  
	A variety of diagnostic studies are available for the diagnosis and staging of pancreatic cancer. Routine laboratory test will reveal laboratory values that  indicate decrease pancreatic function. The diagnosis of pancreatic cancer, however, is typically made radiographically and histologically
	Surgery is not always an option for these patients because of the sudden loss of their supply of insulin along with the cancer.  The Whipple procedure is a surgery that is sometimes performed which involves removal of parts of the small intestine, bile duct, stomach and head of the pancreas.  In some cases that spleen is also removed.  Chemotherapy may improve quality of like, but has not proven to increase survival.

References

John’s Hopkins. Basics of pancreatic cancer (2007). Retrieved October 29, 2007 from
http://pathology.jhu.edu/pancreas/BasicSymptom.php?area=ba 
Pancreatic cancer (2002). Retrieved October 28, 2007 from 
http://www.medicinenet.com/pancreatic_cancer/article.htm 
Pancreatic cancer (2007). Retrieved October 28, 2007 from
http://en.wikipedia.org/wiki/Pancreatic_cancer 
www. Health.harvard.edu/fhg/updates/update0803d.shtml
www.mayoclinic.com/health/pancreac-cancer
www.hmc.psu.edu/healthinfo/pq/pancreaticcancer.htm
www.uptodateonline.com (2007). Retrieved October 30, 2007