Pancreatic Ca

Question 1

Pancreatic Ca

Answer 1

Pancreatic cancer is often diagnosed late as it tends to present in a non-specific way. Over 80% of pancreatic tumours are adenocarcinomas which typically occur at the head of the pancreas.

Question 2

Pancreatic Cancer - Associations

Answer 2

Associations
increasing age
smoking
diabetes
chronic pancreatitis (alcohol does not appear an independent risk factor though)
hereditary non-polyposis colorectal carcinoma
multiple endocrine neoplasia
BRCA2 gene

Question 3

Pancreatic Cancer - Features

Answer 3

Features
classically painless jaundice
however, patients typically present in a non-specific way with anorexia, weight loss, epigastric pain
loss of exocrine function (e.g. steatorrhoea)
atypical back pain is often seen
migratory thrombophlebitis (Trousseau sign) is more common than with other cancers

Question 4

Pancreatic Ca - Ix

Answer 4

Investigation
ultrasound has a sensitivity of around 60-90%
high resolution CT scanning is the investigation of choice if the diagnosis is suspected

Question 5

Pancreatic Cancer - Example Question

Answer 5

A 76-year-old man presents with jaundice. He is a heavy drinker, consuming approximately 35-40 units per week. There is no history of abdominal pain, and pain is not elicited on abdominal examination. However, examination does reveal a palpable gallbladder. Bloods are taken and the results are:

Albumin	30 g/L
Alk Phos	342 U/L
ALT	95 U/L
Bilirubin	102 mol/L
INR	1.4
Bilirubin	102 mol/L
GGT	123 U/L

Which of the following is the likely diagnosis?

	Alcoholic hepatitis
	> Pancreatic cancer
	Primary biliary cirrhosis
	Paracetamol overdose
	Gallstones

The correct answer for this question is pancreatic cancer.

Courvoisier’s sign states that in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree.

Alcoholic hepatitis and primary biliary cirrhosis are a reasonable differentials. However, an examination finding of a painless, enlarged gallbladder makes both of these differentials less likely.

The scenario does not suggest paracetamol overdose, as this would not cause a painless, palpable gallbladder. Furthermore, jaundice is not usually seen in paracetamol overdose.

Question 6

Pancreatic Ca - Mx

Answer 6

Less than 20% suitable for surgery at diagnosis
Adjuvant chemo is usually given following surgery
ERCP is used for palliation
Whipple’s resection is used for resectable lesions in the HEAD of pancreas

Question 7

Whipple’s Resection

Answer 7

= PANCREATICODUODENECTOMY
Performed for resectable lesions in the head of the pancreas

= Removal of head of pancreas, duodenum inc duodenal ampulla, proximal jejune, the GB and often the distal stomach

SE:
- Dumping syndrome:
> common after gastric surgery, when food passes through the stomach too rapidly and enters SI undigested
> Early Sx = within 15-30 mins after eating - Nausea and vomiting, Bloating, Cramping, Dizziness, Fatigue, Diarrhoea
> Late Sx = within 1-3h after eating - weakness, sweating, dizziness
- PUD

Question 8

Courvoisier’s Sign

Answer 8

Courvoisier’s sign states that in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree.