The patient

A 76 year old woman with no important medical history presented after six months of intermittent epigastric discomfort and back pain. These symptoms were associated with 1 stone (6.4 kg) of weight loss despite a good appetite. Immediately before referral, she had developed increased flatulence and loose stools. Physical examination was normal. Test results were normal for full blood count; glucose; urea and electrolytes; liver function; upper gastrointestinal endoscopy; and duodenal biopsy.

What is the next investigation?

The differential diagnosis of upper abdominal pain is wide, and investigation depends on eliciting either features in the history or signs that point to an organ of origin. Pancreatic pain, due to either cancer or chronic pancreatitis, classically radiates to the back and is provoked by eating. Occasionally the onset of diabetes helps to point to a pancreatic cause.

In practice, abdominal pain of pancreatic origin has few specific features, and consequently other diagnoses are likely to be considered. Gallstone disease, peptic ulceration, and gastric or colonic cancer are all more common than pancreatic disease, often leading to these systems being investigated first. Ductal adenocarcinoma, the commonest pancreatic neoplasm, has a propensity to affect the pancreatic head and to obstruct the common bile duct so as to cause jaundice. If jaundice develops, …