z Pain that initially starts as a vague upper abdominal pain or back discomfort, which then, becomes progressive, persistent and radiates to the back. z Considerable weight loss, fatigue and change in bowel habits are seen in majority of the patients. z New onset diabetes may be the first sign in 10% of the patients. z Anemia and acute pancreatitis can be a presenting picture as well. z Nausea and vomiting could be a presentation in gastric outlet obstruction. z Patients, with lesions in the pancreatic body and tail, present with weight loss and abdominal pain.
Clinical Examination Jaundice, liver enlargement and a palpable gall bladder are the easily recognizable signs of pancreatic carcinoma during clinical examination. Skin irritation can occur due to extreme pruritis and skin scratching. Cachexia and muscle wasting are the signs of advanced disease.
Lab Investigation The laboratory report will show a raised level of serum total, direct bilirubin, al kaline phosphatase and gamma glutamyl transpeptidase. Patients with pancreatic body and tail lesions often have nor-
mal values and develop abnormalities only on a later stage indicating diffuse metastatic disease. CA 19-9 will be elevated above the normal value of 37units /ml in 75% in patients having the disease. CA 19-9 as an independent test, not sensitive or specific to, warrants screening the population.
Diagnostic Imaging Ultrasound examination gives information regarding distended gall bladder, liver metastasis, pancreatic masses, peripancreatic adenopathy and ascites. CT scan of abdomen with contrast reveals pancreatic mass lesion, spread to liver peripancreatic nodes and retroperitoneal structures. CT scan gives information regarding major vessel encasement, invasion and helps in planning the resectabilty of the tumour. MRCP will provide information about tumour size, extent, biliary involvement and vascular involvement. ERCP should be considered in patients with common bile duct or pancreatic obstruction without pancreatic mass. ERCP may be useful in placing biliary stent to decompress the biliary tree. PTBD will help in better defining proximal biliary anatomy and the level of bil-
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