Question
A 76-year-old man comes with a 4-month history of gradually worsening loose stools that are greasy, foul-smelling, and difficult to wash away. On examination, his abdomen is soft but a fullness is felt in the right upper abdomen.
His blood tests show a cholestatic pattern of liver enzymes with elevated bilirubin and alkaline phosphatase.
Which investigation is most appropriate to confirm the suspected diagnosis?
a. Plain abdominal radiograph
b. Stool pancreatic enzyme estimation
c. Ultrasound scan of abdomen
d. Contrast-enhanced CT scan focused on pancreas
e. Serum lipase
Answer
Contrast-enhanced CT scan focused on pancreas
Detailed Explanation
This patient has classic features suggestive of pancreatic head malignancy, particularly:
- Steatorrhoea (fatty stools) → indicates pancreatic exocrine insufficiency
- Painless obstructive jaundice → cholestatic LFTs
- Palpable right upper quadrant mass → likely distended gallbladder
This combination is explained by Courvoisier’s law, which suggests malignant obstruction (commonly pancreatic cancer) rather than gallstones.
Why CT Pancreas is Best
- Pancreatic cancer is best diagnosed with high-resolution contrast-enhanced CT
- It provides:
- Tumor detection
- Local invasion assessment
- Vascular involvement
- Metastasis staging
- It can demonstrate the “double duct sign” (dilated bile duct + pancreatic duct)
Why Other Options Are Wrong
- Ultrasound
- Useful initial test but operator-dependent and less sensitive
- Abdominal X-ray
- No role in diagnosing pancreatic tumors
- Faecal elastase
- Assesses pancreatic function, not diagnosis of malignancy
- Serum amylase/lipase
- Useful in pancreatitis, not cancer diagnosis
Cheat Sheet for Exam
Pancreatic Cancer – Key Points
Risk Factors
- Age
- Smoking
- Diabetes
- Chronic pancreatitis
- BRCA2 mutation
Classic Presentation
- Painless jaundice
- Pale stools + dark urine
- Weight loss
- Back pain
- Steatorrhoea
Important Clinical Sign
- Courvoisier law → palpable gallbladder = malignancy
Best Investigation
- CT pancreas (gold standard imaging)
Other Clues
- Double duct sign
- Migratory thrombophlebitis (Trousseau syndrome)
Flashcards
Q1. What is the best initial definitive imaging for suspected pancreatic cancer?
A. Contrast-enhanced CT pancreas
Explanation: Provides best sensitivity and staging information
Q2. What does steatorrhoea indicate in pancreatic disease?
A. Exocrine insufficiency
Explanation: Lack of lipase → fat malabsorption
Q3. What does Courvoisier law suggest?
A. Malignancy causing biliary obstruction
Explanation: Palpable gallbladder + painless jaundice → not gallstones
Q4. What is the double duct sign?
A. Dilated bile duct + pancreatic duct
Explanation: Seen in pancreatic head tumors
Q5. Which pancreatic tumor location most commonly causes jaundice?
A. Head of pancreas
Explanation: Compresses common bile duct
MCQs (Challenging Level)
MCQ 1
A 70-year-old man presents with painless jaundice and weight loss. Which imaging modality is most sensitive for diagnosis?
a. MRI liver
b. Ultrasound abdomen
c. CT pancreas
d. ERCP
e. PET scan
Answer: c. CT pancreas
Explanation: CT is first-line for diagnosis and staging; ERCP is mainly therapeutic.
MCQ 2
Which of the following is false regarding pancreatic cancer?
a. Most tumors occur in the pancreatic head
b. Steatorrhoea suggests exocrine insufficiency
c. Ultrasound is more sensitive than CT
d. Smoking is a risk factor
e. Double duct sign may be present
Answer: c. Ultrasound is more sensitive than CT
Explanation: CT is more sensitive and preferred modality.
MCQ 3
A patient has palpable gallbladder with jaundice. What is the most likely diagnosis?
a. Gallstones
b. Chronic cholecystitis
c. Pancreatic malignancy
d. Acute hepatitis
e. Hemolysis
Answer: c. Pancreatic malignancy
Explanation: Courvoisier law—palpable gallbladder suggests malignant obstruction.
MCQ 4
Which feature is most specific for pancreatic exocrine failure?
a. Hyperglycemia
b. Steatorrhoea
c. Jaundice
d. Elevated amylase
e. Ascites
Answer: b. Steatorrhoea
Explanation: Fat malabsorption is hallmark of exocrine insufficiency.
MCQ 5
Which paraneoplastic phenomenon is associated with pancreatic cancer?
a. Polycythemia
b. Trousseau syndrome
c. SIADH
d. Hypercalcemia
e. Nephrotic syndrome
Answer: b. Trousseau syndrome
Explanation: Migratory thrombophlebitis due to malignancy.
MCQ 6
Which investigation is primarily therapeutic rather than diagnostic in pancreatic cancer?
a. CT scan
b. Ultrasound
c. ERCP
d. MRI
e. PET
Answer: c. ERCP
Explanation: Used for biliary stenting and palliation.
Summary for Quick Exam Revision
Pancreatic cancer, most commonly arising in the head of the pancreas, typically presents late with painless obstructive jaundice, weight loss, and steatorrhoea due to exocrine insufficiency. A key clinical clue is Courvoisier law, where a palpable gallbladder in the presence of jaundice suggests malignancy rather than gallstones. Laboratory findings often show a cholestatic pattern with elevated bilirubin, ALP, and GGT. The investigation of choice is a contrast-enhanced CT scan of the pancreas, which not only confirms the diagnosis but also assesses local invasion, vascular involvement, and distant metastases. Imaging may reveal the characteristic double duct sign. Ultrasound may be used initially but is less sensitive. ERCP is mainly reserved for palliation via biliary stenting. Prognosis is poor as most patients present late, and only a minority are candidates for surgical resection such as the Whipple procedure.