Pancreatic Cancer Clinical Presentation

Updated: Jun 13, 2022
  • Author: Tomislav Dragovich, MD, PhD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Presentation

History

The initial symptoms of pancreatic cancer are often quite nonspecific and subtle. Consequently, these symptoms can be easily attributed to other processes unless the physician has a high index of suspicion for the possibility of underlying pancreatic carcinoma.

Patients typically report nonspecific symptoms such as vague digestive discomfort, bloating, anorexia, nausea, fatigue, mid-epigastric or back pain, and weight loss. Mid-epigastric pain may radiate to the mid- or lower back. Radiation of the pain to the back is worrisome, as it indicates retroperitoneal invasion of the splanchnic nerve plexus by the tumor. The pain may be worse when the patient is lying flat.

Weight loss may be related to cancer-associated anorexia and/or subclinical malabsorption from pancreatic exocrine insufficiency caused by pancreatic duct obstruction by the cancer. Patients with malabsorption usually complain about diarrhea and malodorous, greasy stools. Nausea and early satiety from delayed gastric emptying due to gastric outlet obstruction from the tumor may also contribute to weight loss.

The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless obstructive jaundice. Patients with this sign may come to medical attention before their tumor grows large enough to cause abdominal pain. These patients usually notice a darkening of their urine and lightening of their stools before they or their families notice the change in skin pigmentation. Pruritus may accompany and often precedes clinical obstructive jaundice. Pruritus can often be the patient's most distressing symptom.

Physicians can usually recognize clinical jaundice when the total bilirubin reaches 2.5-3 mg/dL. Patients and their families do not usually notice clinical jaundice until the total bilirubin reaches 6-8 mg/dL. 

Depression is reported to be more common in patients with pancreatic cancer than in patients with other abdominal malignancies. In some patients, depression may be the most prominent presenting symptom, or its onset may precede that of somatic symptoms. [50] Researchers have proposed that the depression associated with pancreatic cancer is a paraneoplastic syndrome caused by the dysregulation of inflammatory cytokines. [51] In addition, although patients may not communicate it to their families, they are often aware that a serious illness of some kind is occurring in them. Men with pancreatic adenocarcinoma have a risk of suicide that is almost 11 times higher than the remainder of the population. [52]

Migratory thrombophlebitis (ie, Trousseau sign) and venous thrombosis also occur with higher frequency in patients with pancreatic cancer and may be the first presentation. [53] Marantic endocarditis may develop in pancreatic cancer, occasionally being confused with subacute bacterial endocarditis.

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Physical Examination

Pain is the most common presenting symptom in patients with pancreatic cancer. About two thirds of patients with pancreatic cancer present with pain; the pain is mild to moderate in one third of patients and severe in one third. All patients experience pain at some point in their clinical course.

As noted in History, the pain typically takes the form of mild to moderate midepigastric tenderness. In some cases, the pain radiates to the midback or lower back; this is worrisome, as it indicates retroperitoneal invasion of the celiac plexus by the tumor.

Clinical jaundice may be present. Patients with clinical jaundice may also have a palpable gallbladder (ie, Courvoisier sign) and may have skin excoriations from pruritus.

Patients presenting with or developing advanced intra-abdominal disease may have ascites, a palpable abdominal mass, hepatomegaly from liver metastases, or splenomegaly from portal vein obstruction.

Subcutaneous metastases (referred to as a Sister Mary Joseph nodule or nodules) in the paraumbilical area signify advanced disease. A metastatic node may be palpable behind the medial end of the left clavicle (Virchow node).

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