Pancreatic cancer differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]


Pancreatic cancer must be distinguished from other pancreatobiliary pathologies that cause abdominal pain and jaundice such as acute suppurative cholangitis, acute cholecystitis, cholelithiasis, chronic pancreatitis, primary biliary cirrhosis and primary sclerosing cholangitis. Pancreatic cancer must also be differentiated from other pancreatic pathologies such as autoimmune pancreatitis, pancreatic pseudocyst, and neuroendocrine tumors of the pancreas. Pathologies of the bile duct and duodenum such as Choledocholithiasis, gallstones (cholelithiasis), choledochal cysts, Cholangiocarcinoma, Bile duct strictures and ampullary cancer should be differentiated from pancreatic cancer based on imaging and biopsy findings. Metastasis from different sites and vascular causes such as abdominal aortic aneurysms may also mimic pancreatic cancer.

Differentiating Pancreatic Cancer from other Diseases

Pancreatic cancer may also be distinguished from other causes of abdominal pain and jaundice as depicted in the table below:

Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Fever Rigors and chills Abdominal Pain Jaundice Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis + + RUQ + + + + N
  • Abnormal LFT
  • WBC >10,000
Ultrasound shows biliary dilatation/stents/tumor Septic shock occurs with features of SIRS
Acute cholangitis + RUQ + N Abnormal LFT Ultrasound shows biliary dilatation/stents/tumor Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis + RUQ + Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis + Epigastric ± ± N Increased amylase / lipase Ultrasound shows evidence of inflammation Pain radiation to back
Primary biliary cirrhosis RUQ/Epigastric + N Increased AMA level, abnormal LFTs
Primary sclerosing cholangitis + RUQ + N
Cholelithiasis ± RUQ/Epigastric ± + + N to hyperactive for dislodged stone Leukocytosis Ultrasound shows gallstone Murphy’s sign
Pancreatic cancer Epigastric ± N

 ill defined hypoechoic mass is seen infiltrating into a bright pancreatic parenchyma

Signs of metastatic disease include: 
Gastric causes Gastrointestinal perforation + ± Diffuse ± + + ± WBC> 10,000 Air under diaphragm in upright CXR
Intestinal causes Whipple's disease ± Diffuse ± ± N *Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Celiac disease Diffuse ±, also dermatitis herpetiformis Hyperactive (increased sounds)
Hepatic causes Viral hepatitis + RUQ + +
Liver masses + + in Liver abscess RUQ ± + in sepsis
Budd-Chiari syndrome ± RUQ
Hemochromatosis RUQ ± + in cirrhotic patients may be in cardicmyopathy >60% TS
>240 μg/L SF
Raised LFT
Ultrasound shows evidence of cirrhosis Extra intestinal findings:
Cirrhosis + RUQ +
Peritoneal causes Spontaneous bacterial peritonitis + Diffuse + in cirrhotic patients ± Hypoactive
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis
Hollow Viscous Obstruction Biliary colic RUQ + N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting

Differentials based on weight loss, nausea, vomiting, diarrhea, fatigue and abdominal pain

Pancreatic carcinoma should be differentiated from other diseases presenting with weight loss, nausea, vomiting, diarrhea, fatigue and abdominal pain. The differentials include the following:

Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Nausea or vomiting Jaundice Constipation Diarrhea Weight loss GI bleeding Hypo-


Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Chronic pancreatitis Epigastric ± ± + + N CT scan
  • Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric + + + + N

Skin manifestations may include:

Dumping syndrome Lower and then diffuse + + + + Hyperactive
  • Upper GI series
  • Gastric emptying study

Abbreviations: RUQ= Right upper quadrant of the abdomen, LUQ= Left upper quadrant, LLQ= Left lower quadrant, RLQ= Right lower quadrant, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, IV= Intravenous, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CXR= Chest X ray, IgA= Immunoglobulin A, IgG= Immunoglobulin G, IgM= Immunoglobulin M, CT= Computed tomography, PMN= Polymorphonuclear cells, ESR= Erythrocyte sedimentation rate, CRP= C-reactive protein, TS= Transferrin saturation, SF= Serum Ferritin, SMA= Superior mesenteric artery, SMV= Superior mesenteric vein, ECG= Electrocardiogram

To review a comprehensive differential diagnosis of diseases presenting with abdominal pain, click here.

Differentiating Pancreatic Carcinoma on the basis of involved Organ

The differentials for pancreatic cancer mainly involve pathologies of the pancreas, bile duct, duodenum, lymphovascular tissue or metastasis from other sites. It is difficult to differentiate pancreatic cancer from other neoplasms as they all present with non specific constitutional symptoms. Hence, differentiation is primarily based on anatomic location:[1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]

Origin Disease Diagnostic study of choice
Bile duct




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