Clinical Presentation

The symptomatology of duodenal peptic ulceration has been discussed in the previous chapter. Duodenal neoplasms, although rare, may lead to epigastric pain and obstructive jaundice if present in the region of the ampulla.

Classically acute pancreatitis presents with severe epigastric pain which radiates to the back. Chronic pancreatitis produces less acute, but often intractable, epigastric pain. Complications of acute pancreatitis such as shock, infection of necrotic tissue, bowel ileus, metabolic disturbance and multiorgan failure produce characteristic clinical features.

Bacterial infection in the bile ducts is usually due to secondary infection of obstructed ducts and leads to cholangitis with pain, fever, rigors and jaundice. If severe, the cholangitis may become "ascending" and cause liver abscesses.

Neoplasms of the head of pancreas (excluding the uncinate process), ampulla of Vater and extrahepatic bile ducts lead to obstructive jaundice. Tumours elsewhere in the pancreas do not and so will present later. Obstructive jaundice, because of a lack of absorption of fat and increased excretion of bilirubin in the urine, leads to light-coloured faeces and dark urine. In general, pancreatic and bile duct neoplasms result in vague, poorly localised epigastric pain, anorexia and weight loss.

Figure 33. Pancreas and ampulla of Vater: regional lymph nodes are peripancreatic (1-4, 11), pancreaticoduodenal (5, 8), splenic hilar (10), proximal mesenteric (7), common bile duct (9) and coeliac (12). Reproduced with permission from Hermanek P, Hutter RVP, Sobin, LH, Wagner, G, Wittekind, Ch. (Eds). TNM Atlas: Illustrated guide to the TNM/pTNM classification of malignant tumours, 4th edition. Springer-Verlag: Berlin and Heidelberg, 1997.

Figure 33. Pancreas and ampulla of Vater: regional lymph nodes are peripancreatic (1-4, 11), pancreaticoduodenal (5, 8), splenic hilar (10), proximal mesenteric (7), common bile duct (9) and coeliac (12). Reproduced with permission from Hermanek P, Hutter RVP, Sobin, LH, Wagner, G, Wittekind, Ch. (Eds). TNM Atlas: Illustrated guide to the TNM/pTNM classification of malignant tumours, 4th edition. Springer-Verlag: Berlin and Heidelberg, 1997.

Tumours of the endocrine pancreas may produce characteristic clinical features because of the hormones they produce:

• insulinoma - psychiatric/neurological symptoms

• gastrinoma - Zollinger-Ellison syndrome

• glucagonoma - diabetes mellitus and skin rash

• VIPoma - watery diarrhoea, hypokalaemia and achlorhydria (WHDA) syndrome.

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