Diagnosis and Clinical Staging
Early diagnosis of pancreatic cancer is challenging; the pancreas is inaccessible to clinical examination, and early symptoms such as vague abdominal discomfort, nausea, anorexia, and weight loss are nonspecific. Specific signs and symptoms of jaundice and epigastric/back pain arise only as the tumor enlarges and invades or obstructs adjacent structures. Indeed, it is not unusual for a patient with pancreatic cancer to be diagnosed within a few months of cholecystectomy performed for abdominal complaints due to presumed gallbladder disease.
Jaundice is the most common physical finding in patients with pancreatic cancer, as most tumors arise in the head of the gland and obstruct the intrapancreatic portion of the common bile duct. The clinical finding of painless jaundice in an appropriate aged patient (fifth to sixth decade of life) must be considered pancreatic cancer until proven otherwise. The jaundice may be associated with darkening of the urine, acholic stools, and pruritus. Occasionally, hepatomegaly or an enlarged gallbladder (Courvoisier gallbladder) may be palpable on physical examination. Although less common, patients should also be examined for the presence of lymphadenopathy in the left supraclavicular (Virchow's node) and periumbilical (Sister Mary Joseph's node) distribution. Fine-needle aspiration biopsy of these nodes proves stage IV disease and allows treatment to be focused on palliation. Occasionally a “dropped metastasis” may be palpable on rectal examination (Blumer's shelf).
The pain associated with pancreatic cancer is typically epigastric and frequently radiates to the back. Pain may be caused ...