A 69-Year Old Black Man Is Evaluated Because of a History

Multiple Choice

A 69-year old black man is evaluated because of a history of steadily increasing upper abdominal pain, loss of appetite, and a 4.6-kg (1 0-Ib) weight loss over the past several months. He recently noticed that the color of his urine was darker than usual. The patient had a 40-pack-year history of cigarette smoking, but quit smoking 4 years ago. He has hypertension that is controlled by medical management. Laboratory studies: Hemoglobin 11.5 g/dL Serum total bilirubin 3.3 g/dL Serum albumin 3.2 g/dL Serum aspartate aminotransferase 105 U/L Serum alanine aminotransferase 95 U/L Urinalysis shows elevated bilirubin. CT scan of the abdomen shows dilation of the common bile and pancreatic ducts, a 5.2-cm mass in the head of the pancreas, and compression of the superior mesenteric vein. A fine-needle aspirate of the mass reveals atypical cells that are suspicious for malignancy. What is the most appropriate course of action?

A) Refer the patient for exploratory laparotomy, biopsy, and biliary bypass
B) Request a CT-guided biopsy of the mass in the head of the pancreas to establish a diagnosis
C) Obtain a consultation for endoscopic retrograde cholangiopancreatography and possible biopsy and biliary stent placement
D) Refer the patient to a tertiary-care center with surgical expertise in the management of patients with pancreatic and hepatobiliary disease