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{{Pancreatic cancer}}
{{Pancreatic cancer}}
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==Overview==
==Overview==
During physical examination, a clinician may find characteristics of pancreatic cancer in a patient. These include: tenderness, weight loss, or jaundice.
[[Patient|Patients]] with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with [[Medical sign|signs]] of [[malnutrition]]. Patients mostly present with [[Palpation|palpable]] [[abdominal mass]], [[epigastric]] [[tenderness]] radiating to the back, [[Organomegaly|hepatospleenomegaly]] and [[Medical sign|signs]] of [[metastasis]] in advanced stages. These [[Medical sign|signs]] of [[metastasis]] include left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), [[Palpation|palpable]] periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') and the involvement of other [[Lymph node|nodes]] in the [[cervical]] area.
==Physical Examination==
 
*Physical examination of patients with [[pancreatic cancer]] is usually remarkable for: [[epigastric]] [[tenderness]], [[jaundice]], and [[Palpation|palpable]] intra abdominal mass.
*The presence of left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), palpable periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') on physical examination is diagnostic of [[metastasis]].
*The presence of [[ascites]] and a palpable, non tender [[Gallbladder|gall bladder]] on physical examination is a common finding in [[pancreatic cancer]] patients.
 
===Appearance of the Patient===
Patients with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with signs of [[malnutrition]]. Patients mostly present with palpable [[abdominal mass]], [[epigastric]] [[tenderness]] radiating to the back, [[Organomegaly|hepatosplenomegaly]] and signs of [[metastasis]] in advanced stages. These signs of [[metastasis]] include left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), palpable periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') and the involvement of other [[Lymph node|nodes]] in the [[cervical]] area.
 
===Vital Signs===


==Physical Examination==
*Regular [[pulse]]
*Normal [[blood pressure]]
*Normal body temperature
 
===Skin===
Skin findings are as follows: <ref name="pmid4005804">{{cite journal |vauthors=Kalser MH, Barkin J, MacIntyre JM |title=Pancreatic cancer. Assessment of prognosis by clinical presentation |journal=Cancer |volume=56 |issue=2 |pages=397–402 |year=1985 |pmid=4005804 |doi= |url=}}</ref><ref name="pmid15522652">{{cite journal |vauthors=Khorana AA, Fine RL |title=Pancreatic cancer and thromboembolic disease |journal=Lancet Oncol. |volume=5 |issue=11 |pages=655–63 |year=2004 |pmid=15522652 |doi=10.1016/S1470-2045(04)01606-7 |url=}}</ref><ref name="pmid3958764">{{cite journal |vauthors=Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G |title=Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center |journal=J. Clin. Oncol. |volume=4 |issue=4 |pages=509–14 |year=1986 |pmid=3958764 |doi=10.1200/JCO.1986.4.4.509 |url=}}</ref><ref name="pmid1330387">{{cite journal |vauthors=Ostlere LS, Branfoot AC, Staughton RC |title=Cicatricial pemphigoid and carcinoma of the pancreas |journal=Clin. Exp. Dermatol. |volume=17 |issue=1 |pages=67–8 |year=1992 |pmid=1330387 |doi= |url=}}</ref><ref name="pmid3164230">{{cite journal |vauthors=Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T |title=Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients |journal=Cancer |volume=62 |issue=1 |pages=135–41 |year=1988 |pmid=3164230 |doi= |url=}}</ref>
*[[Jaundice]]: Yellowish discoloration of [[skin]], [[sclera]]
**Associated with [[Palpation|palpable]], non-tender and distended [[gallbladder]] at the right costal margin ([[Courvoisier's law|Courvoisier's sign]])<ref name="pmid19190960">{{cite journal |vauthors=Fitzgerald JE, White MJ, Lobo DN |title=Courvoisier's gallbladder: law or sign? |journal=World J Surg |volume=33 |issue=4 |pages=886–91 |year=2009 |pmid=19190960 |doi=10.1007/s00268-008-9908-y |url=}}</ref> 
**[[Excoriation|Excoriations]] of the [[skin]] from unrelenting [[Itch|pruritus]] 
**Darkening of the [[urine]] 
** [[Acholic stools|Acholic]] [[Human feces|stools]] 
* [[Pallor]] ±
* [[Skin]] manifestations may include:
** [[Bullous pemphigoid]]
** [[Mucous membrane pemphigoid|Cicatricial pemphigoid]]
** [[Thrombophlebitis|Migratory superficial thrombophlebitis]] (classic [[Trousseau's syndrome]])
** [[Panniculitis|Pancreatic panniculitis]]:
*** Associated with [[Acinar cell|acinar cell variant]] of [[pancreatic cancer]]
*** Located mostly on the legs
*** Appears as an [[Erythema|erythematous]] [[Subcutaneous tissue|subcutaneous]] area of [[Nodule (medicine)|nodular]] [[fat necrosis]]
The following picture depicts [[bullous pemphigoid]] [[Lesion|lesions]] in a [[patient]]:
 
[[Image:Pancreatic_cancer_-_Bullous_pemphgoid.jpg|thumb|350px|center|CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42563781]]
 
{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}}
 
===Neck===
*Signs of [[Metastasis|metastatic disease]] include: <ref name="pmid9490607">{{cite journal |vauthors=Galvañ VG |title=Sister Mary Joseph's nodule |journal=Ann. Intern. Med. |volume=128 |issue=5 |pages=410 |year=1998 |pmid=9490607 |doi= |url=}}</ref>
**Left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]])
**Palpable periumbilical mass (''Sister Mary Joseph's node'')
**[[Metastasis|Metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'')
**Involvement of other [[Lymph node|nodes]] in the [[cervical]] area


:*The initial presentation varies according to location of the cancer.
===Abdomen===
::*Malignancies in the pancreatic body or tail usually present with tenderness and weight loss, while those in the head of the gland typically present with [[steatorrhea]], weight loss, and [[jaundice]]. The recent onset of atypical [[Diabetes Mellitus]], a history of recent but unexplained [[thrombophlebitis]] ([[Trousseau's sign]]).
Abdominal examination is as follows: <ref name="pmid8780535">{{cite journal |vauthors=Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T |title=Clinicopathologic features of small pancreatic adenocarcinoma. A collective study |journal=Cancer |volume=78 |issue=5 |pages=986–90 |year=1996 |pmid=8780535 |doi=10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A |url=}}</ref><ref name="pmid3942423">{{cite journal |vauthors=Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R |title=Collective review of small carcinomas of the pancreas |journal=Ann. Surg. |volume=203 |issue=1 |pages=77–81 |year=1986 |pmid=3942423 |pmc=1251042 |doi= |url=}}</ref><ref name="pmid11075985">{{cite journal |vauthors=Mujica VR, Barkin JS, Go VL |title=Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants |journal=Pancreas |volume=21 |issue=4 |pages=329–32 |year=2000 |pmid=11075985 |doi= |url=}}</ref>
*[[Abdominal distention]]
*[[Abdominal tenderness]]:
**Site: [[tenderness]] in [[Epigastric|mid epigastric]] region 
**Onset: insidious 
**Character: gnawing, visceral quality 
**Radiation- mid/lower back due to [[tumor]] invasion of the [[Retroperitoneum|retroperitoneal]] [[Splanchnic nerve|splanchnic nerve plexus]] 
**Relieving factors: relieved on lying down in a curled or [[Fetus|fetal]] position may improve the pain 
**Aggravating factors: worse on lying supine or eating 
**Timing: intermittent 
**Severity- mild-moderate, worse at night
*An [[abdominal mass]] may be palpable in the epigastrium.
*[[Hepatomegaly]] may arise from liver [[metastasis]]
*[[splenomegaly]] may arise from portal vein obstruction
*[[hepatosplenomegaly]]
*Fluid thrill and dullness to [[percussion]] may be present due to [[ascites]]


::*[[Courvoisier's law|Courvoisier sign]] defines the presence of jaundice and a painlessly distended [[gallbladder]] as strongly indicative of pancreatic cancer, and may be used to distinguish pancreatic cancer from [[gallstone]]s.
===Genitourinary===
*In advanced stages of [[pancreatic cancer]], [[Metastasis|metastatic]] palpable mass may be present in the [[rectal]] pouch.(''Blumer's shelf'')


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}


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Latest revision as of 15:03, 27 November 2017

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

Overview

Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatospleenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.

Physical Examination

Appearance of the Patient

Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatosplenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.

Vital Signs

Skin

Skin findings are as follows: [1][2][3][4][5]

The following picture depicts bullous pemphigoid lesions in a patient:

CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42563781

{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}}

Neck

Abdomen

Abdominal examination is as follows: [8][9][10]

Genitourinary

References

  1. ↑ Kalser MH, Barkin J, MacIntyre JM (1985). "Pancreatic cancer. Assessment of prognosis by clinical presentation". Cancer. 56 (2): 397–402. PMID 4005804.
  2. ↑ Khorana AA, Fine RL (2004). "Pancreatic cancer and thromboembolic disease". Lancet Oncol. 5 (11): 655–63. doi:10.1016/S1470-2045(04)01606-7. PMID 15522652.
  3. ↑ Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G (1986). "Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center". J. Clin. Oncol. 4 (4): 509–14. doi:10.1200/JCO.1986.4.4.509. PMID 3958764.
  4. ↑ Ostlere LS, Branfoot AC, Staughton RC (1992). "Cicatricial pemphigoid and carcinoma of the pancreas". Clin. Exp. Dermatol. 17 (1): 67–8. PMID 1330387.
  5. ↑ Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T (1988). "Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients". Cancer. 62 (1): 135–41. PMID 3164230.
  6. ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
  7. ↑ Galvañ VG (1998). "Sister Mary Joseph's nodule". Ann. Intern. Med. 128 (5): 410. PMID 9490607.
  8. ↑ Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T (1996). "Clinicopathologic features of small pancreatic adenocarcinoma. A collective study". Cancer. 78 (5): 986–90. doi:10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A. PMID 8780535.
  9. ↑ Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R (1986). "Collective review of small carcinomas of the pancreas". Ann. Surg. 203 (1): 77–81. PMC 1251042. PMID 3942423.
  10. ↑ Mujica VR, Barkin JS, Go VL (2000). "Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants". Pancreas. 21 (4): 329–32. PMID 11075985.

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