Synopsis
Treat progressive painless jaundice as a possible pancreaticobiliary malignancy, obtain staging-quality imaging before elective drainage, and separate urgent sepsis care from a coordinated tissue and resection pathway.
- In a person aged 40 or over, NICE recommends suspected pancreatic-cancer pathway referral for jaundice; do not wait for pain, a palpable gallbladder or profound bilirubin elevation.
- Confirm conjugated cholestasis and assess haemoglobin, renal function, coagulation, albumin and inflammatory markers while checking for immediate cholangitis.
- Ultrasound can show duct dilatation and gallstones, but it cannot reliably stage a pancreatic, ampullary or bile-duct cancer.
Key red flags
Progressive jaundice with pale stools, dark urine, pruritus, weight loss or new diabetes requires urgent pancreaticobiliary cancer assessment.
Fever or rigors after biliary stenting may represent stent occlusion and cholangitis even when abdominal pain is absent.
Confusion, hypotension, oliguria or rising lactate marks organ dysfunction and must accelerate antimicrobial and drainage decisions.
Rigors, fever, hypotension or confusion converts a stable cancer investigation into an acute cholangitis pathway requiring antibiotics and decompression.
Investigation priorities
Confirm conjugated cholestasis, establish synthetic and renal consequence, and look for infection or anaemia before imaging and intervention.
Management branches
A stable afebrile adult has progressive painless jaundice, cholestatic liver tests and ultrasound duct dilatation.
- Arrange urgent pancreatic-protocol CT before endoscopic or percutaneous drainage, while correcting dehydration and procedural coagulation risk.
- Refer CT images to the HPB MDT to assess resectability. When CT shows localised pancreatic disease and cancer treatment is planned, offer FDG-PET/CT for staging even when the primary diagnosis is already clear.