Patient profile

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Valerie Stephenson is 63 years old and has lived alone since her husband died from a heart attack 12 years ago. Valerie has 3 grown up children and 3 grandchildren. 

Valerie lives alone in the large family house, and has a good circle of friends, who are very supportive. She spends a good deal of time with her partner Harry, but they do not formally live together. Valerie takes regular holidays across the world with her “girl friends”.

She has no significant past medical history, and is not someone who visits the GP regularly.

First appointment

After some pressure from her daughter, she visits her GP, Dr Najjar, with a range of symptoms.

 
Dr Najjar suggested that Valerie take some ibuprofen regularly to manage the pain, and asked that she return in a month to make sure that things had settled down.
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Summary of symptoms

• Loose bowel movements and stomach cramps (which settled)
• Weight loss – but Valerie was dieting
• Feelings of indigestion
• Pain/ache in rib area radiating round to the back

Valerie is keen to underplay her symptoms.

Presentation of pancreatic cancer

There are often no symptoms in the early stages of pancreatic cancer, which makes it particularly hard to diagnose. Some of the presenting symptoms may not be specific to pancreatic cancer and can be caused by a number of conditions. Dr Sarah Taylor,
GatewayC GP Lead talks to Mr Thomas Satyadas, Consultant General Surgeon, about the common symptoms of pancreatic cancer.

Key points:

• Presenting symptoms of pancreatic cancer can be vague and may have a lot of different causes
• It is important to ask specifically about:
• steatorrhea – foul-smelling or pale stools which may be difficult to flush
• signs of jaundice – pale stools, dark urine
• Back pain is often a late sign of pancreatic cancer
• Safety-netting is key and patients should be given clear instructions about when to return if their symptoms do not settle.

New onset diabetes

Pancreatic tumours can stop the pancreas from producing insulin, leading to an onset of diabetes. Because all the pancreas is not needed to regulate body insulin levels, diabetes can be an early or late stage sign of pancreatic cancer. However, Cancer Research UK also recognises diabetes as being a risk factor for developing pancreatic cancer.

NICE NG12 guidelines recommend an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 and over with weight loss and new onset diabetes.

Key points:

• Unexplained new onset diabetes should be investigated as a possible indicator of pancreatic cancer.
• It is important to ask patients about other symptoms of pancreatic cancer such as steatorrhea, back pain and weight loss

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Student information

Presentation

• Abdominal pain
• Jaundice
• Change in bowel habit
• Steatorrhea (pale stools)
• Weight loss
• New onset diabetes

Jaundice

Jaundice is one of the most common and earliest signs that a person may have pancreatic cancer.

It is worth remembering some of the differential diagnoses of painless jaundice in older patients:

• Pancreatic cancer
• Other biliary tumours (cholangiocarcinoma, ampullary carcinoma, gallbladder cancer
• Liver disease (alcoholic, fatty) or Hepatitis
• Chronic pancreatitis or auto-immune pancreatitis
• PSC (Primary Sclerosing Cholangitis
• Post-surgical strictures
• Lymphadenopathy

History

1. Presenting complaint & history of presenting complaint
   • For abdominal pain, think SOCRATES

     

   • Changes in bowel habit? Remember to ask about steatorrhea
   • Any other symptoms of jaundice? Yellow skin? Conjunctiva? Dark urine? Pale stools? Itching?
   • Any symptoms of new onset diabetes? Polydipsia? Polyuria?
   • Timeline of symptoms?
2. Ideas, Concerns, Expectations, Impact on life
3. Past Medical History – Previous malignancies? Chronic pancreatitis?
4. Medication History
5. Social – Smoking, alcohol intake and diet?
6. Family History – Pancreatitis? Pancreatic cancer?
7. Systems review – Fatigue, Lethargy, Appetite change, Weight loss (quantify and identify if on purpose)

Key: Signs and symptoms of pancreatic cancer
Physical examination

1. General Inspection

   Scars, Stomas (indications of any previous abdominal surgeries), Cachexia/Obesity, Jaundice

   Hands

   Finger clubbing (IBD), Koilonychia (iron deficiency anaemia)

   Face

   Conjunctival jaundice, conjunctival pallor (iron deficiency anaemia), Angular stomatitis (iron deficiency anaemia), Glossitis (IBD, anaemia), Aphthous ulcers (IBD, anaemia)

   Abdomen

   Masses (identify size, texture, mobility), Hepatomegaly (potential metastases), Lymphadenopathy, Tenderness

   Legs

   Erythema nodosum, Pyoderma gangrenosum (IBD), Swelling (possible DVT)

Additional resources

Link: Signs and symptoms of pancreatic cancer, Pancreatic Cancer UK (2020)
Link: Pancreatic cancer symptoms, Cancer Research UK (2019)
Link: Primary Care 10 Top Tips – Pancreatic Cancer, Macmillan Cancer Support and Pancreatic Cancer UK (2020)
Link: Pancreatic cancer – Suspected cancer: recognition and referral, NICE (2021)
Link: Diabetes and Pancreatic Cancer, Molecular Carcinogenesis Vol 51:1 (2012)