PassFinals
Gastroenterology & Nutrition

Pancreatic Cancer

Pancreatic cancer is most often an exocrine ductal adenocarcinoma; it may present with obstructive jaundice, weight loss, upper-abdominal or back pain, new diabetes or malabsorption, and treatment depends on specialist staging and whether the tumour is resectable.

In a nutshell

Pancreatic cancer is usually an exocrine ductal adenocarcinoma. Painless jaundice suggests a head tumour; body and tail tumours may present with weight loss, upper-abdominal or back pain, new diabetes or malabsorption. Use urgent NICE referral criteria and pancreatic-protocol CT before biliary drainage, then classify resectability in a specialist HPB MDT. Surgery plus adjuvant chemotherapy is the potentially curative pathway; other disease needs systemic, obstructive, nutritional, pain and palliative management matched to fitness and goals.

Classic presentation

A person aged over 40 presents with painless progressive jaundice, dark urine, pale stools, pruritus and weight loss, sometimes with a palpable non-tender gallbladder; body or tail cancer may instead cause pain, weight loss or new diabetes without jaundice.

Key points

  • Jaundice aged 40 or over requires a suspected cancer pathway referral; age 60 or over with weight loss plus specified gastrointestinal symptoms or new diabetes warrants urgent direct-access CT, or ultrasound if CT is unavailable.
  • In suspected pancreatic cancer with obstructive jaundice, perform pancreatic-protocol CT before biliary drainage.
  • Use CT of the chest, abdomen and pelvis plus selected EUS, tissue sampling, MRI/MRCP, PET/CT or laparoscopy to stage and answer a specific diagnostic question.
  • The specialist HPB MDT decides resectability; do not equate a visible mass with operability.
  • Resectable disease may receive pancreatoduodenectomy or distal pancreatectomy followed by adjuvant chemotherapy; NICE NG85 limits routine neoadjuvant therapy to clinical-trial pathways.
  • Give pancreatic enzyme replacement when indicated, address pain and malnutrition early, and provide palliative and clinical nurse specialist support from diagnosis.

First-line investigation

Pancreatic-protocol contrast CT, before biliary drainage when obstructive jaundice is present.

Management

Refer urgently and image before drainage

  • Use NICE NG12 referral criteria and arrange pancreatic-protocol CT before draining obstructive jaundice; suspected cholangitis needs urgent infection and biliary-source-control management.6,1

Stage in the specialist HPB MDT

  • Classify the tumour as resectable, borderline resectable, locally advanced or metastatic using pancreatic-protocol CT and selected tissue or staging tests, then agree care with the person in the specialist MDT.1,4

Match treatment to resectability and fitness

  • Offer specialist resection followed by adjuvant chemotherapy when resectable and fit; use clinical-trial or specialist pathways for borderline disease, systemic treatment for locally advanced disease and performance-status-based regimens for metastatic disease.1,7,8

Control obstruction, pain, nutrition and thrombosis risk

  • Use specialist biliary or duodenal decompression when needed, provide pancreatic enzyme replacement and early enteral nutrition when indicated, treat pain actively and individualise cancer-associated VTE prevention.1,10,9,3

Maintain specialist follow-up and safety-netting

  • Provide ongoing specialist review, investigate new or unresolved symptoms promptly and give urgent advice for fever with jaundice, worsening pain, persistent vomiting, inability to eat or drink, confusion or thromboembolic symptoms.1,3

Exam traps

  • Courvoisier's sign is a clue, not a diagnosis; ultrasound or CT is still needed.
  • Do not drain obstructive jaundice before the pancreatic-protocol CT unless an emergency such as cholangitis requires immediate intervention.
  • CA 19-9 does not diagnose pancreatic cancer and is confounded by cholestasis and Lewis-antigen status.
  • A normal bilirubin does not exclude a body or tail tumour.
  • Do not offer routine neoadjuvant therapy for resectable or borderline resectable disease outside the NICE clinical-trial framing.
  • Pancreatin, pain control, diabetes care and nutrition are active cancer management, not optional extras.

Illustrations

Double-duct sign on CTAxial contrast-enhanced CT showing dilatation of the common bile duct and pancreatic duct, with a clear annotation that the double-duct sign is a clue to obstruction rather than a diagnosis by itself.Chaudhary S et al., Cureus 2025, CC-BY-4.0 · CC-BY-4.0

Key sources

  1. NICE NG85: Pancreatic cancer in adults: diagnosis and management (NG85 recommendations; page last reviewed 17 September 2025)Published 7 Feb 2018 | Updated 17 Sept 2025
  2. NHS: Symptoms of pancreatic cancer (Current NHS symptom and urgent-assessment information)Updated 9 Jun 2023
  3. NHS: Treatment for pancreatic cancer (Current NHS treatment and supportive-care information)Updated 9 Jun 2023
  4. NHS England: HPB – pancreatic and periampullary cancers service specification (Service specification 2325)Published 18 Sept 2024
  5. NHS: Tests and next steps for pancreatic cancer (Current NHS diagnostic and specialist-pathway information)Updated 9 Jun 2023
  6. NICE NG12: Suspected cancer: recognition and referral (Recommendations organised by site of cancer and symptom-based referral recommendations)Published 23 Jun 2015 | Updated 15 Apr 2026
  7. BNF: Capecitabine (Current prescribing monograph)
  8. BNF: Gemcitabine (Current prescribing monograph)
  9. BNF: Pancreatin (Current prescribing monograph)
  10. NICE NG89: Venous thromboembolic diseases: diagnosis, management and thrombophilia testing (Recommendations on VTE prevention in people with cancer)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.