This case involves a 60-year-old female patient in Illinois who had a history of pancreatic cancer that had gone into remission some time before the incident in question. The patient presented to her general practice physician with complaints of generalized stomach pain. Despite her previous history of pancreatic cancer, she was treated conservatively with prescription nausea and pain medication. Nevertheless, she soon developed symptoms of vomiting and diarrhea and was referred to a gastroenterologist. The gastroenterologist performed a colonoscopy, however no conclusive results were obtained. Her symptoms persisted and she began to lose weight, however despite multiple visits to her family doctor in the ensuing time nothing further was done. It was eventually discovered that she had developed a new tumor in her pancreas which had spread to her liver.
Question(s) For Expert Witness
- 1. Please discuss your background in treating patients as described in the case summary.
- 2. What is the standard work up when a patient presents with symptoms as described in the case summary?
- 3. What could have been possibly done for the patient to avoid this outcome?
Expert Witness Response E-012134
As Chairman of Internal Medicine at a medical school, I supervise resident outpatient clinics and oversee inpatient care. We see many patients with abdominal pain, and I routinely teach residents about the care of pancreatic cancer patients. Standard of care in this instance includes initial medication therapy, followed by endoscopy and/or colonoscopy, depending on symptoms. If there were no features to suggest malignancy, work-up may stop. If there are worrisome signs or symptoms, like weight loss or thrombophlebitis, abdominal CT scan probably should be ordered. Pancreatic cancer is rarely found early because its symptoms are vague, however abdominal CT may have been indicated in this case given the circumstances.
Expert Witness Response E-006911
I have treated many patients with similar presentations to this. If symptoms persist, then a step-wise, more aggressive diagnostic approach is in order to ascertain the source of the patient’s signs and symptoms. If the colonoscopy and upper endoscopy were both negative then, in my opinion, I think a CT of the abdomen and pelvis was in order to find out why this patient’s symptoms persisted.