Assessment

HISTORY. Cancer of the pancreas has been called a "silent" disease; one reason for the poor survival rate is that cancer is often not detected during its early stages because of its insidious onset. The signs and symptoms are vague and frequently disregarded, or they are attributed to some minor ailment. Abdominal pain is a common sign of advanced pancreatic cancer. Cancer of the body of the pancreas impinge on the celiac ganglion, causing pain. Unplanned weight loss and epigastric pain that may radiate to the back are common complaints. Ask the patient to describe the type and intensity of the pain and also aggravating and relieving factors. Patients often report a dull intermittent pain that has become more intense. Eating and activity often precipitate pain, whereas lying supine or sitting up and bending forward may offer relief. Question the patient as to the presence of any nausea and vomiting (especially that worsens after eating), anorexia, flatulence, diarrhea, constipation, or unusual fatigue.

PHYSICAL EXAMINATION. Inspect the patient for the presence and extent of jaundice, which is the presenting symptom in 80% to 90% of patients with cancer of the pancreatic head. The jaundice may have preceded or followed the onset of pain, but it usually progresses along a distinctive pattern: beginning on the mucous membranes, then on the palms of the hands, and finally becoming generalized. If the cancer blocks the release of pancreatic juices into the intestines, the patient may have difficulty digesting fatty foods; this will result in pale, bulky, greasy stools that tend to float in the toilet. Assess for the presence of pruritus and dark urine, which is caused by a build up of bilirubin in the skin and blood, respectively.

Early tumors can usually not be palpated but auscultate, palpate, and percuss the abdomen. If the tumor involves the body and tail of the pancreas, an abdominal bruit may be heard in the left upper quadrant (indicating involvement of the splenic artery) and a large, hard mass may be palpated in the subumbilical or left hypochondrial region. Note the presence of liver or spleen enlargement. Dullness on percussion may indicate the presence of ascites or gallbladder enlargement.

PSYCHOSOCIAL. Assess for the presence of irritability, depression, and personality changes. The sudden onset of characteristic symptoms can precipitate these emotional responses. Families and patients often display profound grief and disbelief on receiving the diagnosis of pancreatic cancer and a poor prognosis. Assess the specific feelings and fears of the patient and family and also the support systems available and previous coping strategies.

690 Pancreatic Cancer

Diagnostic Highlights

Test

Normal Result

Abnormality with Condition

Explanation

Computed

Normal structure of the

Identifies size and location

Provides detailed images with

tomography

pancreas and surround

of tumors

multiple cross-sections of the

(CT) scan

ing organs and struc-

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