1. Adi Kartolo University of Ottawa

2. Initial Presentation 62-year-old middle class Caucasian male Chief Complaint: pain in upper abdomen and back, significant weight loss, loss of appetite, bloating, change in bowel habit, and nausea. Develop jaundice recently.

3. Hx Has been diagnosed with pancreatitis before. Not taking any medication currently.

4. Hx Cont’d Family Hx: Father had hypertension and CVD Mother had diabetes and chronic pancreatitis

5. Hx Cont’d Social/Occupational Hx: Retired; used to work as a high school teacher Sedentary lifestyle No history of substance abuse Has been smoking and drinking for about 20 years

6. Dietary Habits Low in vegetables and fruits High in red meat High in sugar-sweetened drinks

7. Physical Examinations BMI: 25 Waist circumference: 38 inches BP: 119/76 mmHg HR: 84 beats/minute RR: 12 breaths/minute Normal body temperature

8. More Examination Lungs are clear to auscultation and percussion, no rales or wheezes No focal motor or sensory deficits Examiner felt a mass in the center of the abdomen

9. DDx What test should we order? What organs should we check for?

10. Imaging Studies Abdominal Ultrasound Abdominal CT (Computed Tomography) Endoscopy: endoscopic retrograde cholangiopancreatography (ERCP) vs. laparoscopy Biopsy: percutaneous vs. endoscopic Results indicate the presence of a tumor in the head of the pancreas

11. What’s Next? O.o?

12. Results of the further studies Blood test indicates an elevation of CA 19-9 in the blood. Microscopic examination indicates metatasis towards lymph node and liver

13. Diagnosis ???

14. Treatment ???