Synopsis
Recognise obstructive jaundice and other pancreatic-cancer patterns, stage resectability before intervention, obtain tissue before systemic treatment when required and coordinate biliary drainage, surgery, chemotherapy and supportive care safely.
- Obstructive jaundice is a pivotal clue in Pancreatic cancer: Painless jaundice with pale stool, dark urine and pruritus is typical of a pancreatic-head tumour and requires an urgent cancer pathway.
- Immediate priority in unstable Pancreatic cancer: Resuscitate and give antibiotics for sepsis, obtain urgent biliary and pancreatic specialist input, and arrange source control with endoscopic or percutaneous drainage without delaying for a complete elective staging sequence.
- Pancreatic-protocol contrast CT is used early to define tumour, arterial and venous relations, liver and peritoneal metastases and resectability before biliary intervention where stable. This is the first-line staging examination in suspected pancreatic cancer; specialist MDT review, not the report phrase alone, determines resectability.
- MRI with MRCP refines the next decision because use selectively for problem solving and staging; it complements rather than routinely replaces high-quality pancreatic-protocol CT.
- Stage before disturbing anatomy: Obtain pancreatic-protocol CT before biliary drainage when clinically safe, then review resectability at a specialist hepatopancreatobiliary MDT.
- Relieve biliary obstruction selectively: Prefer a self-expanding metal stent when durable palliation or neoadjuvant treatment is expected, using MDT-specific device planning.
- A major avoidable harm is biliary sepsis; Obstructed or instrumented ducts can become infected, causing septic shock and requiring antibiotics plus urgent drainage.
- A common diagnostic trap is distal cholangiocarcinoma: Both cause painless obstructive jaundice; duct-centred imaging, endoscopy and histopathology distinguish treatment pathways.
Key red flags
Painless progressive jaundice, dark urine, pale stool and pruritus suggest distal malignant biliary obstruction.
Unexplained weight loss, epigastric pain radiating to the back or new anorexia persists in an older adult.
New diabetes, rapidly worsening glycaemia or pancreatitis occurs without another clear explanation.
Fever, rigors, hypotension or confusion accompanies jaundice and indicates possible acute cholangitis.
Persistent vomiting, early satiety or inability to tolerate intake suggests gastric outlet obstruction.
A tender calf, pulmonary embolus or migratory thrombophlebitis may be a thrombotic presentation of occult cancer.
Fever, rigors, jaundice, hypotension or confusion with obstruction is a source-control emergency rather than routine outpatient staging.
Investigation priorities
Define tumour, arterial and venous relations, liver and peritoneal metastases and resectability before biliary intervention where stable.
Management branches
Pancreatic cancer is suspected in a stable patient with jaundice, pain, weight loss or a pancreatic lesion.
- Obtain pancreatic-protocol CT before biliary drainage when clinically safe, then review resectability at a specialist hepatopancreatobiliary MDT.
- Use MRI for liver or duct uncertainty and endoscopic ultrasound core biopsy when neoadjuvant, systemic or non-operative treatment is planned.
- Assess performance, nutrition, diabetes, exocrine insufficiency, thrombosis and hereditary features alongside anatomical staging.