Synopsis
Recognise pancreatic malignancy promptly, stage it without avoidable procedural delay, and coordinate resection, systemic treatment, biliary care, nutrition and symptom control through a specialist multidisciplinary team.
- New obstructive jaundice in a person aged 40 or over warrants an urgent suspected-cancer pathway; fever, hypotension or confusion additionally suggests cholangitis requiring emergency care.
- Pancreas-protocol contrast CT of chest, abdomen and pelvis usually defines the primary lesion, vascular relationships and distant spread before any planned biliary drainage.
- A normal CA 19-9 does not exclude cancer, while cholestasis can raise it substantially; the marker supports assessment and follow-up but never establishes the diagnosis alone.
- Resectability is an anatomical and biological multidisciplinary judgement, not a radiology phrase in isolation; arterial contact, venous reconstructability, metastases, performance status and patient priorities matter.
- Obtain histology before systemic anticancer treatment, usually with endoscopic ultrasound-guided sampling; clearly resectable disease may proceed directly to surgery after specialist review.
- Do not drain every jaundiced patient before surgery: cholangitis, severe symptomatic obstruction, delayed surgery or planned neoadjuvant treatment are common reasons to intervene.
- Offer pancreatic enzyme replacement and dietetic review for resected disease and consider it early in unresectable disease, because maldigestion may be present without classic steatorrhoea.
- Discuss germline and tumour genomic testing according to the current NHS genomic directory because inherited risk and actionable findings may affect relatives or treatment selection.
Key red flags
Jaundice with fever, rigors, hypotension or altered consciousness suggests acute cholangitis and demands immediate sepsis management plus urgent biliary-source control advice.
Persistent vomiting, a succussion splash or inability to tolerate liquids may indicate malignant gastric outlet obstruction and requires urgent fluid correction and specialist decompression planning.
Sudden dyspnoea, pleuritic pain, syncope or unilateral limb swelling should trigger immediate assessment for cancer-associated venous thromboembolism.
Escalating back pain with weakness, sensory change or sphincter disturbance requires emergency investigation for spinal metastatic compression rather than routine analgesic adjustment.
Oliguria, severe thirst, confusion or postural collapse in a jaundiced patient indicates important dehydration, sepsis or renal injury and should not wait for an outpatient cancer appointment.
Investigation priorities
Define cholestasis, organ reserve and immediate complications before contrast imaging or intervention.
Management branches
Jaundice or cholestatic symptoms without an established benign explanation.
- Assess immediately for cholangitis, dehydration, coagulopathy and renal injury; admit and treat urgently when systemic illness is present.
- Arrange pancreas-protocol CT before elective biliary drainage whenever the patient is stable enough, preserving accurate staging information.
- Refer through the urgent pancreatic cancer route and discuss drainage, endoscopic sampling and resectability with the hepatopancreatobiliary multidisciplinary team.
- Use ERCP or alternative drainage when clinically indicated, with antibiotics and stent strategy governed by infection, anatomy and the anticipated treatment sequence.