Clinical features

Clinical features

• Jaundice secondary to obstruction of the distal bile duct is the most common symptom that draws attention to ampul - - lary and pancreatic head tumours. It is characteristically painless jaundice but may be associated with nausea and epigastric discomfort. Pruritus, dark urine and pale stools - with steatorrhoea are common accompaniments of jaundice. - In the absence of jaundice, symptoms are often non-specific, ). namely vague discomfort, anorexia and weight loss, and are frequently dismissed by both patient and doctor. Upper abdominal symptoms in a patient recently diagnosed with diabetes, especially in one above 50 years of age with no todu - family history or obesity , should raise suspicion. Occasionally , a patient will present with an unexplained attack of pancre - atitis; all such patients should have follow-up imaging of the pancreas. Tumours of the body and tail of the gland often gr ow silently and present at an advanced unresectable stage. Back pain is a worrying symptom, raising the possibility of retroperitoneal infiltration. On examination, there may be evidence of jaundice, weight loss, a palpable liver and a palpable gallbladder. Courvoisier first drew attention to the association of an enlarged gallblad der and a pancreatic tumour in 1890, when he noted that, when the common duct is obstructed by a stone, distension of the gallbladder (which is likely to be chronically inflamed) is rare; when the duct is obstructed in some other way , such as a neoplasm, distension of the normal gallbladder is common. Other signs of intra-abdominal malignancy should be looked for with care, such as a palpable mass, ascites, supraclavicular nodes and tumour deposits in the pelvis; when present, they indicate a grim prognosis.

(b) Figure 72.33 (a) Carcinoma of the ampulla as seen at endoscopy. (b) Appearance of the same tumour (arrow) on endoscopic ultra /uni00A0 sonography (courtesy of Dr Peter Fairclough).