QuestionSBA
QuestionChoice
Nonspecific lower back pain can only be diagnosed when no other cause of the back pain can be found. Therefore, it is a diagnosis of exclusion. Nonspecific lower back pain would not lead to jaundice
32930
c
Nonspecific lower back pain
QuestionChoice
Liver cirrhosis occurs when the liver tissue because nodules surrounded by widespread fibrosis. This usually occurs over a number of years rather than months. Jaundice is a symptom of liver cirrhosis, but it is often accompanied by ascites and muscle wasting
32929
b
Liver cirrhosis
QuestionChoice
Hepatocellular carcinoma is the most common cancer of the liver. Patients with cirrhosis are at high risk of developing hepatocellular carcinoma. It usually presents with pruritis, jaundice, abdominal distension and right upper quadrant pain
32932
e
Hepatocellular carcinoma
QuestionChoice
Primary biliary cholangitis is often found incidentally. It is an autoimmune disease of the biliary system which eventually leads to scarring, fibrosis and cirrhosis over years or decades. (In its late stages, it can also be called primary biliary cirrhosis). The first symptoms are often fatigue, pruritis and right upper quadrant pain
32931
d
Primary biliary cholangitis
QuestionChoice
Pancreatic cancer classically presents as painless jaundice. There can be some accompanying generalised, nonspecific signs of epigastric or back pain. Painless obstructive jaundice is more likely to occur in tumours of the head of the pancreas. Risk factors for pancreatic cancer include smoking and high alcohol intake, as well as poor diet, diabetes and family history
32928
a
Pancreatic cancer
QuestionComment
Why tanned skin?
12191
User
subscriber
Abscess Otitis
QuestionComment
Tanned and Jaundice are not the same.
16048
User
subscriber
George
QuestionComment
not sure why this can't be PBC? 

18790
QuestionComment
PBC presents with itching, extreme fatigue etc none of which are mentioned in her symptoms
22888
User
subscriber
His Majesty King Charles III
User
subscriber
Contusion Liver
QuestionComment
Tanned skin really threw me off
24520
QuestionComment
yeah was expecting it to be haemachromatosis or something
59699
User
subscriber
Loose Lung
User
subscriber
Poisoned Lyme 
Concept
Chapter
# Summary

Pancreatic cancer, primarily adenocarcinomas, is the fifth leading cause of cancer in the UK with approximately 9,000 new diagnoses annually. Early symptoms such as malaise, abdominal pain, nausea, or weight loss are often non-specific, leading to a late diagnosis. Advanced disease may exhibit complications such as obstructive jaundice, newly diagnosed diabetes in older patients, unexplained pancreatitis, paraneoplastic syndromes, and others. Diagnostic investigations includes ultrasound, CT scan, MRI, MRCP, and endoscopic ultrasound, with biopsy if necessary. Management strategies depend on the stage of the disease; surgical resection, specifically pancreaticoduodenectomy, is the only potentially curative approach for localized disease, while palliative therapies are used for advanced cases.

# Definition

Pancreatic cancer is a malignant neoplasm originating from the pancreatic tissue. The pancreas is a glandular organ involved in both the digestive and endocrine systems of vertebrates. The most prevalent type of pancreatic cancer is pancreatic adenocarcinoma, which usually originates from the head of the pancreas.

# Epidemiology

- Pancreatic cancer ranks as the fifth most common cancer in the UK.
- Adenocarcinomas make up the majority of these cancers, with a poor 5-year survival rate (<5%).
- Each year in the UK, nearly 9,000 new pancreatic cancer cases are diagnosed.
- On average, a full-time GP will diagnose approximately one person with pancreatic cancer every 3-5 years.

# Aetiology

The exact cause of pancreatic cancer remains unknown. However, it is associated with several risk factors:

- Age: Pancreatic cancer is more prevalent in elderly individuals.
- Smoking: The risk significantly increases with tobacco use.
- Obesity: Overweight and obese individuals have a higher risk.
- Diabetes: Long-standing diabetes may increase risk.
- Chronic pancreatitis: Chronic inflammation of the pancreas can lead to cancer.
- Family history: Having a first-degree relative with pancreatic cancer increases the risk.
- Certain genetic syndromes: Genetic mutations linked to pancreatic cancer include BRCA2, Lynch syndrome, and familial atypical mole and melanoma (FAMMM) syndrome.

# Signs and Symptoms

Early-stage pancreatic cancer often presents with non-specific symptoms:

- Malaise
- Abdominal pain
- Nausea
- Weight loss
- Painless jaundice
- Courvoisier's sign - painless jaundice with a palpable gallbladder is usually indicative of a pancreatic or gallbladder malignancy (and less likely due to e.g. gallstones)

Advanced disease can present with complications including:

- Obstructive jaundice, often due to blockage of the common bile duct by a tumour in the pancreatic head. It may present with Courvoisier's sign.
- Diabetes mellitus, typically in an elderly patient with newly diagnosed diabetes and weight loss, may suggest a tumour in the body/tail of the pancreas.
- Pancreatic infiltration can lead to unexplained pancreatitis and pancreatic exocrine dysfunction with steatorrhoea.
- Paraneoplastic syndromes, such as Trousseau's syndrome (migratory thrombophlebitis), or marantic endocarditis.
- Disseminated intravascular coagulation (DIC)

Pancreatic cancer often metastasises early to the lung, liver, and bowel.

# Differential Diagnosis

Conditions with similar presentation to pancreatic cancer include:

- Chronic pancreatitis: Chronic abdominal pain, steatorrhoea, diabetes mellitus.
- Cholangiocarcinoma: Painless jaundice, weight loss, abdominal pain.
- Gastric cancer: Dyspepsia, weight loss, anorexia, nausea and vomiting.
- Hepatocellular carcinoma: Abdominal pain, weight loss, jaundice, hepatomegaly.

# Investigations

### NICE 2-week-wait criteria:

* Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for pancreatic cancer if they are aged 40 years and over and have jaundice.
* Consider an urgent  CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 years and over with weight loss and any of the following: diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation, or new-onset diabetes.

Investigations for pancreatic cancer include:

- Initial assessment with abdominal ultrasound to detect tumours (>2cm), potential liver metastases and any dilation of the common bile duct.
- CT abdomen/pelvis for patients with a high clinical suspicion. This can predict surgical resectability and enables disease staging.
- Magnetic resonance cholangiopancreatography (MRCP) for details about the biliary ducts.
- Endoscopic ultrasound to detect small lesions (2-3mm) and for biopsy if needed.
- PET-FDG and MRI as adjuncts.

# Management

The only potentially curative treatment for pancreatic cancer is surgical resection. However, due to late presentation, only 15-20% of patients present with resectable disease.

Criteria for resection include:

- No evidence of superior mesenteric artery (SMA) or coeliac arteries involvement.
- No evidence of distant metastases.

The common surgical procedure for tumours in the head of the pancreas is the Kausch-Whipple procedure (radical pancreaticoduodenectomy). Adjuvant chemotherapy is offered post-surgery to patients who have recovered well.

In cases of locally advanced or metastatic disease, palliative therapy is the only option. This includes:

- Endoscopic stent insertion into the common bile duct.
- Palliative surgery if endoscopic stent insertion fails.
- Chemotherapy.
- Radiotherapy (only for localised advanced disease).

It is crucial to refer these patients to palliative care services for pain management and psychological support.

# NICE Guidelines

[Click here to see the NICE guidelines on pancreatic cancer](https://www.nice.org.uk/guidance/ng85)
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Pancreatic Cancer
Topic
23
Gastroenterology
6586
Pancreatic cancer typically presents with painless jaundice, often accompanied by nonspecific symptoms like epigastric or back pain, and is more common in tumors of the pancreas head, with risk factors including smoking, high alcohol intake, poor diet, diabetes, and family history.
A 56-year-old woman presents to her GP because her friends tell her that she looks tanned but hasn't been on holiday recently. On further questioning, she admits to some mild back pain, on and off for the last few months, which she has put down to her new exercise regime. She smokes 20-a-day and drinks alcohol "at weekends". On examination, she has scleral icterus and appears to be tanned.

What is the most likely diagnosis?
a