Practice Rational Imaging

Investigation of abdominal pain to detect pancreatic cancer

BMJ 2008; 336 doi: (Published 08 May 2008) Cite this as: BMJ 2008;336:1067
  1. J Ashley Guthrie, consultant radiologist ,
  2. Maria B Sheridan, consultant radiologist
  1. 1Department of of Clinical Radiology, Lincoln Wing, St James’s University Hospital, Leeds LS9 7TF
  1. Correspondence to: J A Guthrie ashley.guthrie{at}

When a patient presents with abdominal pain, which investigations should clinicians use to establish whether the pain results from pancreatic cancer?

Learning points

  • Abdominal ultrasonography identifies about three quarters of pancreatic cancers

  • Dedicated pancreatic computed tomography is the imaging method of choice both for diagnosis and staging of pancreatic pathology

  • Endoscopic retrograde cholangiopancreatography should be reserved for insertion of biliary endoprostheses in those patients who develop jaundice

  • Brush cytology can be done during endoscopic retrograde cholangiopancreatography, with brushings taken from duct strictures

  • Skilled endoscopic ultrasonography is the most sensitive method of detecting small pancreatic tumours and allows biopsy

The patient

A 76 year old woman with no important medical history presented after six months of intermittent epigastric discomfort and back pain. These symptoms were associated with 1 stone (6.4 kg) of weight loss despite a good appetite. Immediately before referral, she had developed increased flatulence and loose stools. Physical examination was normal. Test results were normal for full blood count; glucose; urea and electrolytes; liver function; upper gastrointestinal endoscopy; and duodenal biopsy.

What is the next investigation?

The differential diagnosis of upper abdominal pain is wide, and investigation depends on eliciting either features in the history or signs that point to an organ of origin. Pancreatic pain, due to either cancer or chronic pancreatitis, classically radiates to the back and is provoked by eating. Occasionally the onset of diabetes helps to point to a pancreatic cause.

In practice, abdominal pain of pancreatic origin has few specific features, and consequently other diagnoses are likely to be considered. Gallstone disease, peptic ulceration, and gastric or colonic cancer are all more common than pancreatic disease, often leading to these systems being investigated first. Ductal adenocarcinoma, the commonest pancreatic neoplasm, has a propensity to affect the pancreatic head and to obstruct the common bile duct so as to cause jaundice. If jaundice develops, …

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