AKT · Gastroenterology/Pancreatobiliary

Pancreatic cancer

Pancreatic ductal adenocarcinoma (commonly head of pancreas) — PAINLESS obstructive jaundice

Overview

Usually ductal adenocarcinoma, most often in the HEAD of the pancreas, presenting late with PAINLESS obstructive jaundice (a palpable non-tender gallbladder — Courvoisier's law), weight loss and epigastric/back pain; or new-onset diabetes/migratory thrombophlebitis (Trousseau). Risk: smoking, chronic pancreatitis, hereditary. Poor prognosis; only a minority are resectable (Whipple's). CA19-9 is a marker.

Recognise

PAINLESS obstructive JAUNDICE with dark urine/pale stools/itch (head of pancreas); weight loss, anorexia, epigastric/back pain (body/tail)
COURVOISIER sign: a palpable, NON-tender gallbladder with jaundice → malignant obstruction (not gallstones)
New-onset diabetes in an older adult, migratory thrombophlebitis (Trousseau sign — paraneoplastic), raised CA19-9

Red flags

Painless obstructive jaundice + weight loss → urgent imaging/2-week-wait (pancreatic cancer)
Cholangitis on an obstructing tumour; duodenal/gastric outlet obstruction

Differentials & how to tell them apart

Choledocholithiasis (CBD stone)jaundice but usually PAINFUL ± fever (cholangitis); Courvoisier law: a palpable gallbladder + painless jaundice favours malignancy

Cholangiocarcinoma / ampullary tumourother causes of malignant obstructive jaundice

Chronic pancreatitiscalcification, alcohol — and a risk factor/mimic

Hepatitishepatitic LFTs rather than obstructive

Investigations

Pancreatic-protocol CT (the key staging test); cholestatic LFTs; CA19-9; EUS + biopsy; MRCP/ERCP (with stenting for jaundice). 'Double-duct sign' (dilated CBD + pancreatic duct).

Management

Pancreatic-protocol CT staging → Whipple's (resectable) / chemo ± stent (palliative)

1Urgent imaging for painless obstructive jaundice + weight loss; pancreatic-protocol CT to stage; relieve jaundice (ERCP stent) and obtain tissue (EUS biopsy).Gate: Courvoisier's law — a palpable, NON-tender gallbladder with painless jaundice points to MALIGNANT obstruction (pancreatic/biliary cancer), NOT gallstones; new-onset diabetes or migratory thrombophlebitis in an older adult can herald pancreatic cancer
2Resectable (minority) → Whipple's + adjuvant chemo; unresectable → palliative chemotherapy, biliary stenting, pain/nutrition/thromboprophylaxis.

Surgery (Whipple's pancreaticoduodenectomy) for resectable disease — the only curative option — minority of patients

Chemotherapy (FOLFIRINOX/gemcitabine) ± biliary stenting — adjuvant/palliative; ERCP stent relieves jaundice

Palliative/supportive care — pain, nutrition, enzyme replacement, thromboprophylaxis

Key points

Painless obstructive jaundice + weight loss + palpable non-tender gallbladder (Courvoisier) = pancreatic head cancer. New diabetes/Trousseau thrombophlebitis can be the herald. CT stages; Whipple's for the resectable few. Poor prognosis.

Monitor & prognosis

CA19-9; staging; palliative needs.

Poor (late presentation); better if resectable.

Source: NICE NG85; BSG