Pancreatic cancer physical examination: Difference between revisions
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==Overview== | ==Overview== | ||
Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatospleenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area. | [[Patient|Patients]] with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with [[Medical sign|signs]] of [[malnutrition]]. Patients mostly present with [[Palpation|palpable]] [[abdominal mass]], [[epigastric]] [[tenderness]] radiating to the back, [[Organomegaly|hepatospleenomegaly]] and [[Medical sign|signs]] of [[metastasis]] in advanced stages. These [[Medical sign|signs]] of [[metastasis]] include left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), [[Palpation|palpable]] periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') and the involvement of other [[Lymph node|nodes]] in the [[cervical]] area. | ||
==Physical Examination== | ==Physical Examination== | ||
*Physical examination of patients with pancreatic cancer is usually remarkable for: epigastric tenderness, jaundice, and palpable intra abdominal mass. | *Physical examination of patients with [[pancreatic cancer]] is usually remarkable for: [[epigastric]] [[tenderness]], [[jaundice]], and [[Palpation|palpable]] intra abdominal mass. | ||
*The presence of left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) on physical examination is diagnostic of metastasis. | *The presence of left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), palpable periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') on physical examination is diagnostic of [[metastasis]]. | ||
*The presence of ascites and a palpable, non tender gall bladder on physical examination is a common finding in pancreatic cancer patients. | *The presence of [[ascites]] and a palpable, non tender [[Gallbladder|gall bladder]] on physical examination is a common finding in [[pancreatic cancer]] patients. | ||
===Appearance of the Patient=== | ===Appearance of the Patient=== | ||
Patients with [[pancreatic cancer]] are usually in the sixth decade of life and appear [[Cachexia|cachectic]], with signs of [[malnutrition]]. Patients mostly present with palpable [[abdominal mass]], [[epigastric]] [[tenderness]] radiating to the back, [[Organomegaly|hepatosplenomegaly]] and signs of [[metastasis]] in advanced stages. These signs of [[metastasis]] include left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]), palpable periumbilical mass (''Sister Mary Joseph's node''), [[Metastasis|metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') and the involvement of other [[Lymph node|nodes]] in the [[cervical]] area. | |||
===Vital Signs=== | ===Vital Signs=== | ||
* | *Regular [[pulse]] | ||
* | *Normal [[blood pressure]] | ||
* | *Normal body temperature | ||
===Skin=== | ===Skin=== | ||
*[[Jaundice]]: Yellowish discoloration of skin, sclera | Skin findings are as follows: <ref name="pmid4005804">{{cite journal |vauthors=Kalser MH, Barkin J, MacIntyre JM |title=Pancreatic cancer. Assessment of prognosis by clinical presentation |journal=Cancer |volume=56 |issue=2 |pages=397–402 |year=1985 |pmid=4005804 |doi= |url=}}</ref><ref name="pmid15522652">{{cite journal |vauthors=Khorana AA, Fine RL |title=Pancreatic cancer and thromboembolic disease |journal=Lancet Oncol. |volume=5 |issue=11 |pages=655–63 |year=2004 |pmid=15522652 |doi=10.1016/S1470-2045(04)01606-7 |url=}}</ref><ref name="pmid3958764">{{cite journal |vauthors=Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G |title=Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center |journal=J. Clin. Oncol. |volume=4 |issue=4 |pages=509–14 |year=1986 |pmid=3958764 |doi=10.1200/JCO.1986.4.4.509 |url=}}</ref><ref name="pmid1330387">{{cite journal |vauthors=Ostlere LS, Branfoot AC, Staughton RC |title=Cicatricial pemphigoid and carcinoma of the pancreas |journal=Clin. Exp. Dermatol. |volume=17 |issue=1 |pages=67–8 |year=1992 |pmid=1330387 |doi= |url=}}</ref><ref name="pmid3164230">{{cite journal |vauthors=Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T |title=Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients |journal=Cancer |volume=62 |issue=1 |pages=135–41 |year=1988 |pmid=3164230 |doi= |url=}}</ref> | ||
**Associated with palpable, non-tender and distended gallbladder at the right costal margin (Courvoisier's sign) | *[[Jaundice]]: Yellowish discoloration of [[skin]], [[sclera]] | ||
**Excoriations of the skin from unrelenting pruritus | **Associated with [[Palpation|palpable]], non-tender and distended [[gallbladder]] at the right costal margin ([[Courvoisier's law|Courvoisier's sign]])<ref name="pmid19190960">{{cite journal |vauthors=Fitzgerald JE, White MJ, Lobo DN |title=Courvoisier's gallbladder: law or sign? |journal=World J Surg |volume=33 |issue=4 |pages=886–91 |year=2009 |pmid=19190960 |doi=10.1007/s00268-008-9908-y |url=}}</ref> | ||
**Darkening of the urine | **[[Excoriation|Excoriations]] of the [[skin]] from unrelenting [[Itch|pruritus]] | ||
** | **Darkening of the [[urine]] | ||
** [[Acholic stools|Acholic]] [[Human feces|stools]] | |||
* [[Pallor]] ± | * [[Pallor]] ± | ||
* Skin manifestations may include: | * [[Skin]] manifestations may include: | ||
** Bullous pemphigoid | ** [[Bullous pemphigoid]] | ||
** Cicatricial pemphigoid | ** [[Mucous membrane pemphigoid|Cicatricial pemphigoid]] | ||
** Migratory superficial thrombophlebitis (classic Trousseau's syndrome) | ** [[Thrombophlebitis|Migratory superficial thrombophlebitis]] (classic [[Trousseau's syndrome]]) | ||
** Pancreatic panniculitis: | ** [[Panniculitis|Pancreatic panniculitis]]: | ||
*** Associated with acinar cell variant of pancreatic cancer | *** Associated with [[Acinar cell|acinar cell variant]] of [[pancreatic cancer]] | ||
*** Located mostly on the legs | *** Located mostly on the legs | ||
*** Appears as an erythematous subcutaneous area of nodular fat necrosis | *** Appears as an [[Erythema|erythematous]] [[Subcutaneous tissue|subcutaneous]] area of [[Nodule (medicine)|nodular]] [[fat necrosis]] | ||
The following picture depicts [[bullous pemphigoid]] [[Lesion|lesions]] in a [[patient]]: | |||
[[Image:Pancreatic_cancer_-_Bullous_pemphgoid.jpg|thumb|350px|center|CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=42563781]] | |||
{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}} | |||
===Neck=== | ===Neck=== | ||
*Signs of metastatic disease include: | *Signs of [[Metastasis|metastatic disease]] include: <ref name="pmid9490607">{{cite journal |vauthors=Galvañ VG |title=Sister Mary Joseph's nodule |journal=Ann. Intern. Med. |volume=128 |issue=5 |pages=410 |year=1998 |pmid=9490607 |doi= |url=}}</ref> | ||
**Left supraclavicular lymphadenopathy (Virchow's node) | **Left [[Supraclavicular lymph nodes|supraclavicular]] [[lymphadenopathy]] ([[Virchow's node]]) | ||
**Palpable periumbilical mass (Sister Mary Joseph's node) | **Palpable periumbilical mass (''Sister Mary Joseph's node'') | ||
**Metastatic palpable mass in the rectal pouch (Blumer's shelf) | **[[Metastasis|Metastatic]] palpable mass in the [[rectal]] pouch (''Blumer's shelf'') | ||
**Involvement of other nodes in the cervical area | **Involvement of other [[Lymph node|nodes]] in the [[cervical]] area | ||
===Abdomen=== | ===Abdomen=== | ||
Abdominal examination is as follows: <ref name="pmid8780535">{{cite journal |vauthors=Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T |title=Clinicopathologic features of small pancreatic adenocarcinoma. A collective study |journal=Cancer |volume=78 |issue=5 |pages=986–90 |year=1996 |pmid=8780535 |doi=10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A |url=}}</ref><ref name="pmid3942423">{{cite journal |vauthors=Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R |title=Collective review of small carcinomas of the pancreas |journal=Ann. Surg. |volume=203 |issue=1 |pages=77–81 |year=1986 |pmid=3942423 |pmc=1251042 |doi= |url=}}</ref><ref name="pmid11075985">{{cite journal |vauthors=Mujica VR, Barkin JS, Go VL |title=Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants |journal=Pancreas |volume=21 |issue=4 |pages=329–32 |year=2000 |pmid=11075985 |doi= |url=}}</ref> | |||
*[[Abdominal distention]] | *[[Abdominal distention]] | ||
*[[Abdominal tenderness]]: | *[[Abdominal tenderness]]: | ||
**Site: tenderness in mid epigastric region | **Site: [[tenderness]] in [[Epigastric|mid epigastric]] region | ||
**Onset: insidious | **Onset: insidious | ||
**Character: gnawing, visceral quality | **Character: gnawing, visceral quality | ||
**Radiation- mid/lower back due to tumor invasion of the retroperitoneal splanchnic nerve plexus | **Radiation- mid/lower back due to [[tumor]] invasion of the [[Retroperitoneum|retroperitoneal]] [[Splanchnic nerve|splanchnic nerve plexus]] | ||
**Relieving factors: relieved on lying down in a curled or fetal position may improve the pain | **Relieving factors: relieved on lying down in a curled or [[Fetus|fetal]] position may improve the pain | ||
**Aggravating factors: worse on lying supine or eating | **Aggravating factors: worse on lying supine or eating | ||
**Timing: intermittent | **Timing: intermittent | ||
**Severity- mild-moderate, worse at night | **Severity- mild-moderate, worse at night | ||
*An abdominal mass may be palpable in the epigastrium. | *An [[abdominal mass]] may be palpable in the epigastrium. | ||
*[[Hepatomegaly]] may arise from liver metastasis | *[[Hepatomegaly]] may arise from liver [[metastasis]] | ||
*[[splenomegaly]] may arise from portal vein obstruction | *[[splenomegaly]] may arise from portal vein obstruction | ||
*[[hepatosplenomegaly]] | *[[hepatosplenomegaly]] | ||
*Fluid thrill and dullness to percussion may be present due to ascites | *Fluid thrill and dullness to [[percussion]] may be present due to [[ascites]] | ||
===Genitourinary=== | ===Genitourinary=== | ||
*In advanced stages of pancreatic cancer, metastatic palpable mass may be present in the rectal pouch.(Blumer's shelf) | *In advanced stages of [[pancreatic cancer]], [[Metastasis|metastatic]] palpable mass may be present in the [[rectal]] pouch.(''Blumer's shelf'') | ||
==References== | ==References== | ||
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{{WS}} | {{WS}} | ||
[[Category: Gastroenterology]] | [[Category: Gastroenterology]] | ||
[[Category:Up-To-Date]] | |||
[[Category:Oncology]] | |||
[[Category:Medicine]] | |||
[[Category:Surgery]] | |||
[[Category:Gastroenterology]] | |||
Latest revision as of 15:03, 27 November 2017
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Pancreatic cancer physical examination On the Web |
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Risk calculators and risk factors for Pancreatic cancer physical examination |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]
Overview
Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatospleenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.
Physical Examination
- Physical examination of patients with pancreatic cancer is usually remarkable for: epigastric tenderness, jaundice, and palpable intra abdominal mass.
- The presence of left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) on physical examination is diagnostic of metastasis.
- The presence of ascites and a palpable, non tender gall bladder on physical examination is a common finding in pancreatic cancer patients.
Appearance of the Patient
Patients with pancreatic cancer are usually in the sixth decade of life and appear cachectic, with signs of malnutrition. Patients mostly present with palpable abdominal mass, epigastric tenderness radiating to the back, hepatosplenomegaly and signs of metastasis in advanced stages. These signs of metastasis include left supraclavicular lymphadenopathy (Virchow's node), palpable periumbilical mass (Sister Mary Joseph's node), metastatic palpable mass in the rectal pouch (Blumer's shelf) and the involvement of other nodes in the cervical area.
Vital Signs
- Regular pulse
- Normal blood pressure
- Normal body temperature
Skin
Skin findings are as follows: [1][2][3][4][5]
- Jaundice: Yellowish discoloration of skin, sclera
- Associated with palpable, non-tender and distended gallbladder at the right costal margin (Courvoisier's sign)[6]
- Excoriations of the skin from unrelenting pruritus
- Darkening of the urine
- Acholic stools
- Pallor ±
- Skin manifestations may include:
- Bullous pemphigoid
- Cicatricial pemphigoid
- Migratory superficial thrombophlebitis (classic Trousseau's syndrome)
- Pancreatic panniculitis:
- Associated with acinar cell variant of pancreatic cancer
- Located mostly on the legs
- Appears as an erythematous subcutaneous area of nodular fat necrosis
The following picture depicts bullous pemphigoid lesions in a patient:
{{#ev:youtube|https://youtu.be/7XLKn5G_GeA}}
Neck
- Signs of metastatic disease include: [7]
- Left supraclavicular lymphadenopathy (Virchow's node)
- Palpable periumbilical mass (Sister Mary Joseph's node)
- Metastatic palpable mass in the rectal pouch (Blumer's shelf)
- Involvement of other nodes in the cervical area
Abdomen
Abdominal examination is as follows: [8][9][10]
- Abdominal distention
- Abdominal tenderness:
- Site: tenderness in mid epigastric region
- Onset: insidious
- Character: gnawing, visceral quality
- Radiation- mid/lower back due to tumor invasion of the retroperitoneal splanchnic nerve plexus
- Relieving factors: relieved on lying down in a curled or fetal position may improve the pain
- Aggravating factors: worse on lying supine or eating
- Timing: intermittent
- Severity- mild-moderate, worse at night
- An abdominal mass may be palpable in the epigastrium.
- Hepatomegaly may arise from liver metastasis
- splenomegaly may arise from portal vein obstruction
- hepatosplenomegaly
- Fluid thrill and dullness to percussion may be present due to ascites
Genitourinary
- In advanced stages of pancreatic cancer, metastatic palpable mass may be present in the rectal pouch.(Blumer's shelf)
References
- ↑ Kalser MH, Barkin J, MacIntyre JM (1985). "Pancreatic cancer. Assessment of prognosis by clinical presentation". Cancer. 56 (2): 397–402. PMID 4005804.
- ↑ Khorana AA, Fine RL (2004). "Pancreatic cancer and thromboembolic disease". Lancet Oncol. 5 (11): 655–63. doi:10.1016/S1470-2045(04)01606-7. PMID 15522652.
- ↑ Pinzon R, Drewinko B, Trujillo JM, Guinee V, Giacco G (1986). "Pancreatic carcinoma and Trousseau's syndrome: experience at a large cancer center". J. Clin. Oncol. 4 (4): 509–14. doi:10.1200/JCO.1986.4.4.509. PMID 3958764.
- ↑ Ostlere LS, Branfoot AC, Staughton RC (1992). "Cicatricial pemphigoid and carcinoma of the pancreas". Clin. Exp. Dermatol. 17 (1): 67–8. PMID 1330387.
- ↑ Manabe T, Miyashita T, Ohshio G, Nonaka A, Suzuki T, Endo K, Takahashi M, Tobe T (1988). "Small carcinoma of the pancreas. Clinical and pathologic evaluation of 17 patients". Cancer. 62 (1): 135–41. PMID 3164230.
- ↑ Fitzgerald JE, White MJ, Lobo DN (2009). "Courvoisier's gallbladder: law or sign?". World J Surg. 33 (4): 886–91. doi:10.1007/s00268-008-9908-y. PMID 19190960.
- ↑ Galvañ VG (1998). "Sister Mary Joseph's nodule". Ann. Intern. Med. 128 (5): 410. PMID 9490607.
- ↑ Furukawa H, Okada S, Saisho H, Ariyama J, Karasawa E, Nakaizumi A, Nakazawa S, Murakami K, Kakizoe T (1996). "Clinicopathologic features of small pancreatic adenocarcinoma. A collective study". Cancer. 78 (5): 986–90. doi:10.1002/(SICI)1097-0142(19960901)78:5<986::AID-CNCR7>3.0.CO;2-A. PMID 8780535.
- ↑ Tsuchiya R, Noda T, Harada N, Miyamoto T, Tomioka T, Yamamoto K, Yamaguchi T, Izawa K, Tsunoda T, Yoshino R (1986). "Collective review of small carcinomas of the pancreas". Ann. Surg. 203 (1): 77–81. PMC 1251042. PMID 3942423.
- ↑ Mujica VR, Barkin JS, Go VL (2000). "Acute pancreatitis secondary to pancreatic carcinoma. Study Group Participants". Pancreas. 21 (4): 329–32. PMID 11075985.