Clinical presentation and history taking
When interviewing a patient, it is important to pay attention to three main groups of complaints: pain syndrome, dyspepsia, and signs of general weakness.
Pain is most often localized in the upper abdomen (epigastric region) or the left hypochondrium. A characteristic feature is band-like radiation or referral to the back, left scapula, and shoulder. In acute conditions, pain arises due to impaired outflow of pancreatic juice and the destructive action of enzymes on the tissue. Intensity can be very high (especially with neoplasms). Patients often notice that the pain worsens when lying on their back and subsides when sitting up and leaning forward (the so-called "fetal position").
In addition to pain, dyspeptic disorders (nausea, vomiting) occur.
Chronic lesions manifest with exocrine insufficiency. Its main marker is steatorrhea, which is the appearance of excess neutral fat in the feces. The stool becomes pasty, golden-gray, and difficult to flush.
If a tumor of the pancreatic head compresses the bile ducts, obstructive jaundice develops, accompanied by yellowing of the skin and severe itching.
Physical examination
Due to the deep retroperitoneal location of the pancreas, palpation has low diagnostic value. The deep sliding palpation method allows the organ to be felt only when it is significantly enlarged (usually due to tumor growth).
During the examination, the physician pays attention to skin color (presence of jaundice) and general signs of severe illness, such as cachexia (wasting).
Laboratory diagnostics
Evaluation of laboratory parameters helps confirm inflammation, necrosis, or systemic disorders.
- Enzymatic activity: The baseline test is measuring amylase and lipase levels. Radioimmunoassay allows a more precise assessment of trypsin, elastase, and lipase activity in serum.
- Inflammatory markers: In acute pancreatitis, leukocytosis and an increase in C-reactive protein are observed. A sharp rise in CRP is a predictor of pancreatic necrosis.
- Metabolic disorders: Hypocalcemia and hyperglycemia (decreased insulin production) may occur. Elevated blood sugar is found in 10–30% of patients with chronic inflammation and up to 50% with pancreatic cancer.
Instrumental methods
Both non-invasive and specialized invasive methods are used to visualize the organ.
- Ultrasound — the method of choice. It allows visualization of edema in acute inflammation, areas of induration (fibrosis), as well as cysts or tumors.
- Computed tomography (CT) — prescribed instead of ultrasound if visualization is difficult (e.g., due to obesity or pronounced flatulence).
- Plain radiography — detects calcifications characteristic of chronic processes.
- ERCP (endoscopic retrograde cholangiopancreatography) — contrast injection into the ducts via an endoscope. Excellently visualizes the structure of the pancreatic duct system. In chronic pancreatitis, deformations and alternating dilations/strictures are visible; in tumors, isolated stenosis or complete obstruction is seen.
- Selective angiography — contrast imaging of arteries, necessary to assess the blood supply to neoplasms.
- Radioisotope scanning — performed with selenium-75-selenomethionine, but has the lowest diagnostic accuracy among all methods.
Briefly: answers to topical questions
What specific symptoms can be detected by palpating the gallbladder in a patient with obstructive jaundice caused by pancreatic head cancer?
Palpation of the gallbladder in a patient with obstructive jaundice caused by pancreatic head cancer reveals a sign of tumor obstruction:
- Courvoisier's sign — a significantly enlarged, tense, painless gallbladder with elastic walls is palpated in the presence of jaundice.
Cause: obstruction of the common bile duct by a tumor of the pancreatic head, which disrupts bile outflow.
What fecal laboratory tests are used to definitively confirm exocrine pancreatic insufficiency?
To confirm exocrine pancreatic insufficiency using fecal data, the following are used:
- Coprogram — detection of steatorrhea: an increased content of neutral fat in the stool. Creatorrhea and amylorrhea may also be detected in the coprogram, which are associated, among other things, with pancreatic enzyme deficiency.
- Fecal pancreatic elastase-1 — a value below 200 mcg/g indicates pancreatic insufficiency; 100–200 mcg/g corresponds to moderate exocrine insufficiency, and less than 100 mcg/g indicates severe pancreatic insufficiency.
To remember the signs of exocrine insufficiency, use the mnemonic: Golden-gray color, Excess fat (steatorrhea), Pasty consistency, Aroma (malodorous, although not explicitly stated, easily inferred).
Class and exam questions
Why do patients with pancreatitis assume the "fetal position"?
When lying supine, the pancreas presses more heavily on the retroperitoneal nerve plexuses (solar plexus). Leaning forward reduces this pressure and slightly relieves pain.
What is the difference in duct imaging on ERCP between patients with tumors and those with chronic pancreatitis?
In tumors, an isolated stricture or complete duct obstruction is typically detected. In chronic inflammation, the duct is deformed: areas of stenosis alternate with dilations.
When is CT ordered instead of ultrasound?
CT is preferred if ultrasound does not provide a clear picture due to patient obesity or gas accumulation in the intestines (intestinal obstruction).
What else to study on this topic
- Pathogenesis of pain syndrome in acute pancreatitis
- Mechanism of development of obstructive jaundice in tumors
- Differential diagnosis of steatorrhea
- Hormonal disorders and hyperglycemia in pancreatic diseases
- Technique and risks of ERCP
Master the entire topic in the "Propaedeutics" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Diagnostic methods for pancreatic diseases" and 3,152 more pages of the subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 113 video lessons on the subject
Other topics in the "Digestive System" section
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.