Pancreatic cancer physical examination

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 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.

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.

• Regular pulse
• Normal blood pressure
• Normal body temperature

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}}

• 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

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

• In advanced stages of pancreatic cancer, metastatic palpable mass may be present in the rectal pouch.(Blumer’s shelf)

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