Pancreatic cancer

Question 1

Most common type

Answer 1

Adenocarcinoma typically at the head of the pancreas

Question 2

Associations

Answer 2

Increasing age

Smoking

Diabetes

Chronic pancreatitis

Hereditary non-polyposis colorectal carcinoma

Multiple endocrine neoplasia

BRCA2 gene

KRAS gene mutation

Question 3

Presentation

Answer 3

Painless obstructive jaundice

Non-specific upper abdo or back pain

Unintentional weight loss

Palpable mass in epigastric region

Change in bowel habits

Nausea and vomiting

New onset diabetes or worsening of type 2 diabetes

Question 4

Obstructive jaundice features

Answer 4

Pale stools

Dark urine

Pruritis

Question 5

Courvoisier’s law

Answer 5

Presence of painless obstructive jaundice and a palpable gallbaldder is unlikely to be due to gallstones

Question 6

Referral

Answer 6

Over 40 with jaundice- 2ww

Over 60 with weight loss and additional symptom- direct access CT abdomen
- diarrhoea
- back pain
- abdominal pain
- nausea
- vomiting
- constipation
- new-onset diabetes

Question 7

Investigations

Answer 7

Diagnosis usually based of CT and histology

CT CAP for staging

Ca19-9

MRCP to assess obstruction

ERCP to stent obstruction and biopsy tumour

Question 8

CA19-9 raised in

Answer 8

Pancreatic cancer

Cholangiocarcinoma

Question 9

Management

Answer 9

Less than 20% suitable for surgery at diagnosis

Whipple’s resection for resectable lesions in head of pancreas

Adjuvant chemotherapy

ERCP with stenting in palliation

Question 10

Side effects of Whipple’s resection

Answer 10

Dumping syndrome

Peptic ulcer disease

Question 11

Whipple’s procedure removes

Answer 11

Head of pancreas

Pylorus of stomach

Duodenum

Gallbladder

Bile duct

Relevant lymph nodes

(modified Whipple leaves pylorus in place)