A 59-year-old man with a history of hypertension presents with a 2-month history of weight loss (9.1 kg (20 lb)), malaise, and “yellow skin.” The patient denies any abdominal pain. He drinks alcohol socially (three beers per week on average) and has never used illicit drugs. He has a temperature of 36.8°C, blood pressure of 124/90 mmHg, heart rate of 96 beats per minute, and a respiratory rate of 18 breaths per minute. Physical examination reveals jaundice, but no hepatomegaly or abdominal tenderness. Laboratory results reveal a severely elevated alkaline phosphatase (910 U/L) and negative anti-mitochondrial antibodies.
Which of the following is the most likely diagnosis in this patient?
A. Primary biliary cirrhosisBiliary obstruction secondary to malignancy. The patient in this question is presenting with a severely elevated alkaline phosphatase in the setting of weight loss, jaundice, and malaise. Elevated alkaline phosphatase indicates obstruction, and given the systemic symptoms of weight loss and malaise, the most likely diagnosis is malignancy causing biliary obstruction, specifically pancreatic adenocarcinoma. Remember: the combination of weight loss, painless jaundice, and elevated alkaline phosphatase is highly suggestive of pancreatic cancer! (A) This patient presents with a negative anti-mitochondrial antibody, making primary biliary cirrhosis highly unlikely. (C) Biliary obstruction secondary to gallstones (choledocholithiasis) can present with similar laboratory values (elevated alkaline phosphatase) but usually is accompanied by right upper quadrant pain (not painless jaundice like this patient). (D) Chronic viral hepatitis would not solely elevate the alkaline phosphatase levels; you would also expect elevated aminotransferases. Furthermore, there is no history of hepatitis B or C in this patient’s history.