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Chapter 089. Pancreatic Cancer (Part 2)

Physical Findings Patients with early disease may not have any significant abnormalities detectable on physical examination. Jaundice may be a presenting feature in some; in these patients a palpable, nontender gallbladder (Courvoisier's sign) may be palpated under the right costal margin. Patients with more advanced disease may have an abdominal mass, hepatomegaly, splenomegaly, or ascites. The left supraclavicular lymph node (Virchow's node) may be involved with tumor, or widespread peritoneal disease may be palpable on rectal examination in the pouch of Douglas. Diagnostic Procedures Imaging Studies (Fig. 89-1) Ultrasound is often used as an initial investigation for patients with jaundice, or with. | Chapter 089. Pancreatic Cancer Part 2 Physical Findings Patients with early disease may not have any significant abnormalities detectable on physical examination. Jaundice may be a presenting feature in some in these patients a palpable nontender gallbladder Courvoisier s sign may be palpated under the right costal margin. Patients with more advanced disease may have an abdominal mass hepatomegaly splenomegaly or ascites. The left supraclavicular lymph node Virchow s node may be involved with tumor or widespread peritoneal disease may be palpable on rectal examination in the pouch of Douglas. Diagnostic Procedures Imaging Studies Fig. 89-1 Ultrasound is often used as an initial investigation for patients with jaundice or with less-specific symptoms such as upper abdominal discomfort and is able to assess the biliary tract gall bladder pancreas and liver. Computed tomography CT scanning is preferable to ultrasound even though it is more costly as it is less operator-dependent more reproducible and less susceptible to interference from intestinal gas. The sensitivity and specificity of CT is markedly improved by the use of pancreatic protocol scanning on modern multislice scanners. CT may show a pancreatic mass dilatation of the biliary system or pancreatic duct or distal spread to the liver regional lymph nodes or peritoneum and or associated ascites . When helical CT is combined with the use of intravenous contrast it may also help determine resectability by providing information on the involvement of important vascular structures such as the celiac axis superior mesenteric or portal vessels. Endoscopic retrograde cholangiopancreatography ERCP is also widely used in the diagnosis of pancreatic cancer particularly when CT and ultrasound fail to show a mass lesion and may reveal either stricture or obstruction in either the pancreatic or common bile duct. ERCP can also be used to obtain brushings of a stricture for cytology or for placing stents in order to relieve .