Pancreatic And Biliary Malignancy

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The clinical picture of both pancreatic and biliary cancer is dominated by

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jaundice (from large bile duct obstruction) and itching.

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important clinical features of pancreatic adenocarcinoma.

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Weight loss and recent onset of diabetes

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Risk factors for pancreatic cancer include:

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smoking (strongest)
chronic pancreatitis
familial predisposition
cystic fibrosis.

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Peri-ampullary cancers


These include cancers of:

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the ampulla of Vater
the distal common bile duct
the peri-Vaterian duodenum.

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By far the most common presentation is painless, progressive jaundice and itching. Rarely it presents with

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hyperamylasaemia/ pancreatitis or grey stools (indicating GI blood loss).

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Hepatic metastases

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notably from primaries in the gastrointestinal tract, lung and breast. The commonest, by far, are secondary hepatic deposits from primary colorectal cancer

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Bile duct strictures

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Bile duct strictures can be malignant (cholangiocarcinomas – or benign. The vast majority are the result of iatrogenic injury during cholecystectomy.

Strictures can also be caused by parasitic infestations of the biliary tract and may complicate AIDS.

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Chronic hepatitis The term chronic hepatitis covers three syndromes, all of which are characterised by

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hepatomegaly and persistent abnormalities of the liver function tests:
chronic persistent hepatitis (CPH)
chronic active hepatitis (CAH)
autoimmune chronic active hepatitis

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Cirrhosis
Primary biliary cirrhosis

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unknown aetiology intrahepatic bile ducts are progressively destroyed by an immunological process. It predominantly affects females, with age of onset about 40 years.

Circulating antibodies against mitochondrial constituents

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Aetiologically the cirrhosis may be:

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cryptogenic (cause unknown)
post hepatitic (usually B or C)
alcoholic
primary biliary cirrhosis.

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Assessment of disease severity in cirrhotic patients

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Child-Pugh score/grading (modified from the initial Child- Turcotte)
Paul Brousse Hospital classification system

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Child-Pugh classification of disease severity in cirrhotic patients

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Parameter A B C
Albumin (g/dl) > 3.5 3.0 - 3.5 < 3.0
Bilirubin (mol/l) < 25 25 - 40 > 40
The bilirubin has to be adjusted for patients with primary biliary cirrhosis (A = 5-7, B = 8 –10, C = 11 or more)

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Child-Pugh classification of disease severity in cirrhotic patients

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Parameter A B C
Prothrombin time (s >normal) < 4.0 4 - 6 > 6*
Prothrombin level % > 64 40 - 65 < 40*

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Child-Pugh classification of disease severity in cirrhotic patients

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Parameter A B C
Ascites none controlled refractory
Encephalopathy none minimal advanced

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Portal hypertension
Portal hypertension results from obstruction to the portal venous flow. In the vast majority of cases (80%) it arises on a background of cirrhosis.

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Prehepatic or preparenchymatous due to primary portal vein thrombosis
Hepatic or parenchymatous due to post sinusoidal occlusion of blood flow in the liver, most commonly by regenerating nodules of cirrhosis
Posthepatic occlusion of the small (veno-occlusive disease) or large hepatic veins (Budd Chiari syndrome)