MKSAP Quiz: progressive, dull, epigastric pain
MKSAP Quiz: progressive, dull, epigastric pain
A 73-year-old man is evaluated for a 3-month history of progressive, dull, epigastric pain. The pain is constant and does not radiate. The patient has had early satiety during this time and has lost 13.5 kg (30 lb); he has had mild nausea but no vomiting. The patient has a history of peptic ulcer disease and occasional heartburn; his only medication is an over-the-counter antacid as needed.
On physical examination, the patient appears cachectic; BMI is 19. There is tenderness and fullness in the epigastric region with hepatomegaly. Laboratory studies reveal a hemoglobin of 10.4 g/dL (104 g/L) with a mean corpuscular volume of 74 fL. Bilirubin, aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase concentrations are normal. Esophagogastroduodenoscopy shows a large ulcerated mass in the gastric body with heaped-up edges; biopsy specimens show adenocarcinoma.
Which of the following is the most appropriate next step in the management for this patient?
A. CT scan of the abdomen
B. Endoscopic ultrasonography
C. Helicobacter pylori stool antigen test
D. Positron emission tomography
MKSAP Answer and Critique
The correct answer is A) CT scan of the abdomen. This item is available to MKSAP 15 subscribers as item 48 in the Gastroenterology and Hepatology module.
In a patient with a newly diagnosed gastric adenocarcinoma, the most important next step in staging would be to evaluate for metastatic disease. CT scan of the abdomen would assess for distant metastases, which would be concerning in this patient with profound weight loss and hepatomegaly. If no distant metastases are detected on initial staging, then endoscopic ultrasonography would be a helpful next test, because it can assess depth of invasion, whereas CT cannot accurately assess depth of early lesions. However, ultrasonography is less sensitive at determining metastatic disease, which is why it is not considered the initial test of choice for staging, especially considering most symptomatic patients such as this one have advanced disease at presentation.
Testing for Helicobacter pylori and eradication of the organism if present are recommended in patients with early-stage gastric cancer but would not be of benefit in someone with advanced disease. Positron emission tomography (PET) scanning should be considered preoperatively to follow up suspicious but indeterminate lesions on CT imaging, but it is not recommended as the initial step in staging.
Key Point
- CT imaging is the next step after esophagogastroduodenoscopy in the staging of newly diagnosed gastric adenocarcinoma to evaluate for metastatic disease.