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- 70% in head gland, 30% body or tail
- highly malignant
- 6500 deaths pa
Risk Factors
- Cigarette smoking
- previous gastric resection
- 3x more common in women
- peak incidence 60-80
Spread
- Direct
- common bile duct
- duodenum
- portal vein
- lymph nodes
- para-duodenal peritoneum
- coeliac axis
- porta hepatis
- lesser and greater curves of stomach
- hilum of spleen
- Blood
Presentation
Symptoms
- Weight loss (80%)
- Epigastric pain (60%)
- Obstructive Jaundice
(50%)
- (head of pancreas, secondaries in porta hepatis)
- Acute pancreatitis
(15%)
- Diabetes mellitus (before or after diagnosis)
- Gastric outlet obstruction
- Thrombophlebitis migrans
- Pancreatic steatorrhoea
Also
- Deep Boring back pain
- fatigue
- malaise
- indigestion
- pruritis
Signs
- extremely rare <50, mean age 65
- palpable epigastric mass
- palpable gallbladder
- hepatomegaly
- thrombophlebitis migrans
- splenomegaly (rarely)
- Virchows node
-
Jaundice
- develops insidiously over several weeks
- deep greenish-yellow hue
- pruritus and other distressing symptoms uncommon
- gall bladder palpable (Courvisiers law)
- Obstruction by compression by
- head of pancreas
- metastatic lymph nodes in porta hepatis
- (liver mets rarely cause jaundice)
- unremitting and progressively deepening jaundice
- (cf gall stones - fluctuating, gall bladder pain)
Investigations
- Hb
- FBC
- ESR
- LFTs
- Blood sugar
- ????FOBs +ve
- USS
- masses in pancreas (often small mass obscured by bowel gas)
- liver
- dilated bile ducts
- stones
- ERCP
- duct obstruction
- may show small tumour
- CT scan
- May not detect tumours <2cm
- Degree of invasion
- metastases
- guided biopsy
Treatment
- Only 20% have apparently localised disease with potential for cure by
resection
- Pancreaticoduodenectomy Whipples or PPPD
- operative mortality 5% +
- 5 year survival 20% where resection performed
- 5 fu chemotherapy & radiotherapy extend life from 6 to 10 months
- Adequate analgesia
- blockade of coeliac ganglion
- Total pancreatectomy
- Distal pancreatectomy
- Palliative decompression - Triple bypass
- Endoscopic/percutaneous stenting
Prognosis
- Median survival
- 5 months with palliative therapy
- 18 months with surgery (possible in 8-25% patients)
- Only 2-10% survive 5 years
Other Pancreatic tumours
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