Brief Answer:
Please give details as asked for.

Detailed Answer:
Hi.
Thanks for your query.
To recapitulate: Male/33 - certain from the symptoms that you have early onset of pancreatic cancer - reports attached seen - symptoms details - not mentioned - have following questions:
Questions:

1- I am wondering if I have pancreatic cancer? I am a nervous wreck and need some help. I am afraid that all of my tests have missed the cancer and I am doing these tests too early.
> First of all, please let me know the symptoms that you have in details and in chronology. A good history from the beginning can give lots of diagnosis.
Also please let me know whether there was such incidence in the family/friends/at work or so?

2- I had an Endoscopic Ultrasound done at XXXXXXX Asia Hospital XXXXXXX Is this a reputable place? 12 biopsies taken (Duodenum, Antrum, Jejunum) (See attached Report)
> Endoscopic ultrasound can detect the best of all.
No comments about reputation as I do not know honestly, but will try find for you.

3- Can CT, MRCP, and Endoscopic ultrasound miss Pancreatic Cancer? How good is MRCP and Endoscopic ultrasound?
As said above, EUS is very good and all the tests you have mentioned can not really miss anything.

4- Can small tumours (< 2cm) cause many symptoms?
> Can cause the symptoms depending upon the position it has.

5- Should I get a PET for confirmation?
> Since you have already done the necessary investigations which have not shown any mass in pancreas, PET scan may not be really necessary as it has its own limitations and uses CT scan usually to detect.
Since you are too much anxious, get the one done if you have the facilities.

6- What does hyperechoic pancreatic duct wall but not dilated mean? Does this suggest pancreatitis or pancreatic cancer? Could you explain this in simple terms?
> Echogenicity is the character that is picked and has the main factor of differentiation among different tissues. Increased echo that is hyperechoic means the signals are coming back than would be found out in a normal tissue and indicated edema or so.
Since the pancreatic duct is not dilated but still hyperechoic means there is edema. This can be simply an inflammation and may not suggest that whether there is pancreatitis or cancer. Serial tests alone may give a clue.

I hope these answers your query.
Please give feedback and feel free to ask for further relevant queries if you feel that there is a gap of communication.

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Brief Answer:
Differential diagnosis can be IBS or so.

Detailed Answer:
Hi.
Thanks for your feedback.
To recapitulate: Male/33 - loss of weight 3 kg in 2 months - frequent bowel movements in XXXXXXX - loss of appetite and loss of muscles mass - bloating and turned off by foods most of the times - normal blood work including that of liver functions - night sweats for past 10 days and sweating on eating and walking up simple stairs -
If all the tests are normal including the stool (if done), I would prefer to consider few differential diagnosis:

IBS- irritable bowel syndrome. Instigated and/or enhanced by the stress and the anxiety which I can feel in your all the queries.

If the stool tests shows infection or any other findings, get treated accordingly.

I said there can be inflammation of the duct itself, not of the pancreas both are different..

There can be insufficiency of the pancreatic enzymes or can be intolerance to certain foods, beverages, additives or so on.

Gall bladder polyp of below 6 mm needs to be followed only as are to be considered as benign.

Since you have undergone the battery of investigations, it is prudent to say that there is no cancer at the moment. Hence the symptoms can be due to other reasons that are to be found out. The treatment can be empirical many a times.

You can rule out pancreatic cancer based on the investigations you have undergone.
You should not think of any malignancies at the moment.

Other tests to rule out other GI malignancies:

Colonoscopy
Tumor markers like CEA, urinary level of 5-HIAA (24 hours collection) are the commonest markers seen for.

I would advise you the following:

To get started with the proper medical management of the problems and see the results.
Avoid foods and beverages that instigate or enhance your problems.
Avoid stress and/or anxiety at any cost.

I hope this answers your queries, feel free to ask for further relevant queries.

Regards

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Brief Answer:
Opinions and treatment received till now...Please.

Detailed Answer:
Hi.
I have already written above about what ideally should you do.
Get a proper medical treatment.
See the results and carry on further treatment under the guidance of your Doctors.
If the muscle mass decreases the weight loss is very prominent.
In cancer cachexia the loss of fat and muscles is very pronounced, so much so that it is called as cachexia.
Since all the reports you have done with show no mass, the chances that you are suffering from cancer are least.
PET scan detect cancer is the cancer absorbs the radioactive sugar more than the normal body tissues and hence can be picked up by the scanner.
It usually detects the masses more than 8 mm and are metabolically highly active.
It also has false positives.
Secondly, PET may not be good for all types of cancers.
The best available knowledge is with the Radiologist who deals and reports PET scans.

You have not mentioned the treatment you have received till now and the opinion of the Doctors at XXXXXXX Asia Hospital, XXXXXXX This is a reputed Institute as per the recent knowledge.

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Brief Answer:
As detailed below.

Detailed Answer:
Thanks for your feedback, further queries and insistence.
Already seen the Reports that you have posted and are in depth and self explanatory.
EUS shows small polypi in gall bladder less than 6 mm and hence benign and needs revision from time to time. Pancreas has been scanned in whole length and there is no mass or dilatation of the pancreatic duct nor any pancreatitis, only hyperechoic pancreatic ''duct wall'' which does not signify any serious problem at all as we had already discussed.
Biopsy report shows eosinophilic infiltration of duodenum and jejunum, and Helicobacter gastritis and hence you were rightly put on the medicines.

Get an appointment with an Oncologist to rule out any malignancy as you are still suspecting.

Not seen such small tumors causing severe symptoms as you have asked for and EUS would have definitely got the small tumors too.

I think you have cancerphobia and you should seek the medical treatment for this if all the investigations including the clinical evaluation, examination and further investigations like PET scan or so are all normal.

It is always best to stick to one Doctor or a Team of Doctors in a single set up as it becomes easy to get assessed by all means and to get a curative treatment.

Whipple's surgery is a big surgery, risky and is not done unless there is an an indication for it, never done on prophylaxis basis.

Please feel free to ask for further relevant queries til you are satisfied, we are here to assist you t the maximum.

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Brief Answer:
As discussed in details.

Detailed Answer:
Since thanks for your appreciation.
To answer your further queries:
1- I have uploaded my CT and MRCP reports. Could you kindly have a look and let me know if anything jumps out at you?
>MRCP on 17 March is reported normal.
> CT Abdomen on March 1 says: Narrowing of the proximal celiac axis by median arcuate ligament, to correlate with symptoms of median arcuate syndrome. (this gives pain in upper abdomen which may increase with food and may be associated with anorexia and weight loss)
: Colonic diverticulosis without inflammation (Diverticulitis)
> MRCP on 12 March says: Multiple lesions in gall bladder, favors polyps, probably benign, with possibility of a small calculus.Needs interval follow up.

In view of the confusing reports, I would advise you to have ultrasonography of the abdomen and particularly for gall bladder to see if there are polyps and/or stones and to act upon such a report as discussed below.


2- My CEA, CA19-9, PSA markers have come back normal.
> This is a good development and assuring too.

3- DO you think lymphoma or some other type of malignancy could be responsible for my symptoms?
> As discussed earlier, there are some medical conditions that can cause the symptoms yo have and should be clinically assessed and treated accordingly, see if there is improvement or not. If there is no improvement after a clinical trial with appropriate medications, a possibility of such a cause that you are afraid about can be thought so.

4- Do you feel any other investigations are necessary?
> Ultrasonography revisions for gall bladder condition and if the polyp are 6 mm or larger, gall bladder removal can be considered by Laparoscopy. Laparoscopy also gives the chance to visualize the actual interior of the abdomen and have diagnostic Laparoscopy at the same time.

Hence the need is as discussed preferably under the supervision of a Gastroenterologist and Surgical Gastroenterologist to have proper clinical evaluation, examination, further studies if required and to go for further treatment as may be needed to get the reports, results and relief.

I hope this answer helps you.

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Brief Answer:
As explained and answered.

Detailed Answer:
Sincere thanks for your appreciation.
Please carry on, we are here to help you.
Please refer to above discussion, we have already covered many of the points.
EUS is endoscopic ultrasound and definitely the best one but you need to undergo endoscopy again. In view of the conflicting as just discussed in the last para, the easiest way is to have abdominal ultrasound, an easy thing to do and you get one more opinion, confirmation of the precious reports, to make sure.
All the tests and reports have their own limitations.

Final questions:

1-I am sorry, but I didn't get your answer to my previous question: Can small tumours cause pain in the abdomen?
> Already discussed; the pain will depend upon the location of the tumour. If it is pressing any of the important structures, it can cause symptoms.

2- What actually causes the pain in pancreatic cancer? The cancer cells themselves or their growth?
> The pain is caused by the growth and obviously of the cancer cells. Pain can be caused by its rapid growth, pressure on any nerves, referred pain in the back as this is a retroperitoneal structure and so on.

3- How big does pancreatic cancer have to be to cause symptoms?
> Big enough to be seen by any of the investigations you have undergone.
There is no certain relationship about the size and the symptoms as every patient will have different sets of symptoms hence a clear idea is difficult to set.

I hope these answers help you further.

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