Intended for healthcare professionals

Practice Easily Missed?

Pancreatic cancer

BMJ 2014; 349 doi: (Published 31 October 2014) Cite this as: BMJ 2014;349:g6385
  1. Ajith K Siriwardena, professor of hepatobiliary surgery12,
  2. Alison M Siriwardena, salaried general practitioner3
  1. 1Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester M13 9WL, UK
  2. 2University of Manchester, Manchester, UK
  3. 3Bramhall Park Medical Centre, Stockport, UK
  1. Correspondence to: A K Siriwardena ajith.siriwardena{at}

The bottom line

  • Consider the diagnosis of pancreatic cancer in all patients presenting with painless obstructive jaundice and refer for further assessment

  • Consider the diagnosis in patients with persistent non-specific gastrointestinal symptoms combined with recent onset or atypical back pain or recent onset diabetes

  • Early referral, assessment, and surgical resection with adjuvant chemotherapy are the mainstays of care for patients with resectable disease, but most patients are not candidates for surgery

  • In patients with unresectable disease, direct treatment towards the relief of jaundice, adequate analgesia, establishment of a tissue diagnosis, consideration of chemotherapy, pancreatic exocrine replacement, and appropriate palliative care

A 74 year old man who had been self medicating with antacids for recurrent indigestion consulted his general practitioner when symptoms persisted for three months. After assessment his GP prescribed a proton pump inhibitor and arranged review in four weeks. Two months later he developed back pain and was prescribed paracetamol with advice about mobilisation. Within four weeks he developed jaundice with dark urine and was admitted to his local hospital. Contrast enhanced computed tomography confirmed a diagnosis of locally advanced, unresectable pancreatic cancer (figure). He received palliative chemotherapy but died five months later.

Contrast enhanced computed tomogram of the upper abdomen showing a hypodense (dark) mass (M) in the head of the pancreas. Note that an endobiliary stent (E) is in situ

Pancreatic cancer

More than eight in 10 cases of pancreatic cancer are ductal adenocarcinoma arising from the epithelium of the exocrine pancreas.1 Obstruction of the lower common bile duct gives rise to the classic presentation of painless obstructive jaundice (dark urine, pale stools, and pruritus owing to hyperbilirubinaemia).2 Tumours can also arise …

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