Pancreatic cancer: symptoms

Symptoms of pancreatic cancer are polymorphic and largely depend on the location, type and size of the tumor, its relationship to nearby organs, the duration of the disease (stage), the presence or absence of metastases. Symptoms of the initial stage of pancreatic carcinoma are rather vague: weight loss, anorexia, dyspepsia, weakness, disability; their frequency is different. It is more indicative that none of these symptoms can be eliminated, and gradually their growth takes place, new symptoms are added. In connection with this "uncertainty" of symptoms, patients turn to the doctor late, not earlier than 2-3 months after the first signs of the disease (40%), and most - after 6 and even 12 months, an average of 4.5 months. Unfortunately, and methods of accurate instrumental and laboratory diagnosis of this disease until relatively recently were absent (only 20-15 years ago - ultrasound, CT, etc.) were developed and became available. Therefore, even with the relatively early treatment of some patients for medical care (but with indistinct clinical symptoms), physicians were not able to make those studies that would allow them to confirm the presence of a pancreatic tumor if they suspected of an oncological disease.

At their disposal there were only indirect, little informative methods, such as, for example, radiologic determination of the distance between the spine and the stomach, signs of compression of the duodenum with an enlarged pancreas head (Frostberg symptom), acceleration of the ESR. In this regard, the stage of polyclinic or hospital examination often required the repetition of research and observation of the patient in dynamics and took a long time - sometimes several weeks or more. As a result, a radical operation could be performed only in 10-25% of patients. However, in most cases, the most disturbing symptoms of patients and forcing them to see a doctor (but this is not the earliest signs of this disease!) Are pain in the upper half of the abdomen, anorexia, weight loss, turning into cachexia, dyspeptic phenomena, general malaise, temperature increase.

In a later period, patients almost always experience a complete loss of appetite, which can be called anorexia pancreatica. Both loss of appetite and exhaustion are an early, constant and always progressive symptom; a significant decrease in body weight (by 10-20 kg or more for 2-3 months) occurs almost always with this type of cancer. Frequent dyspeptic symptoms (nausea, vomiting, diarrhea), which are unavoidable in the defeat of the digestive tract; Noteworthy are steatorrhoea and creatorrhea, which occur in 10-15% of cases. Seldom marked fever.

Pain in the abdomen with pancreatic cancer is very often (in 70-80%); they differ in some features. With cancer of the head of the pancreas, pain is more often localized in the right hypochondrium, sometimes resembling pain with ulcer disease, cholecystitis, attacks of cholelithiasis. The pains are dull, sometimes burning, cruel in nature, felt deep in the abdomen (sometimes radiating to the right - with a head injury or to the left - with cancer of the tail of the gland). Pains are usually not associated with eating or with other circumstances and do not leave the patient either day or night (nocturnal pains). For the cancer of the body and tail of the pancreas, pain is even more characteristic, often appearing at the forefront as the earliest and leading symptom of the disease, often they are extremely painful, unbearable. Pain in this cancer location is observed in the epigastric region or the left upper quadrant of the abdomen, often acquires a shingling character; in more rare cases, they are localized in the lumbar region. Pain often radiates into the spine (lower thoracic and upper lumbar vertebrae), left shoulder blade, shoulder, chest area. These pains are associated with the pressure or germination of the tumor of the nerve trunks of the celiac plexus located behind the pancreas, i.e. These are solar pains, often irradiating to all areas of the abdomen. In the supine position on the back pains in many cases intensify, which depends on the increase in tumor pressure on the celiac plexus. Therefore, often patients with pancreatic cancer take a forced position: sitting, slightly bent forward or lying on their stomachs or on their sides, bending their legs; in these positions the pains have a somewhat lower intensity, since the pressure of the pancreas and the intestines located in front of it, the anterior wall of the abdomen, on the celiac and other nerve plexuses and nerve trunks decrease.

For cancer, localized in the head of the pancreas, characterized by the development of mechanical (podchechenochnoy) jaundice with some increase in the liver and a positive symptom of Courvoisier (palpable, overgrown with bile, painless gallbladder) due to compression and germination of the tumor of the common bile duct or, less often, the compression of the hepatic ducts increased due to tumor metastases by lymph nodes in the gates of the liver. The appearance of jaundice is not preceded by an attack of cholelithiasis colic, it arises gradually, imperceptibly at first, until it attracts the attention of the patient and others. Having arisen, jaundice quickly grows, and the patient's skin gradually acquires a greenish, greenish-gray or dark olive color (due to the transformation of bilirubin, which stains the skin and other tissues, into biliverdin); Hyperbilirubinemia reaches 260-340 μmol / l (15-20 mg%) and higher. As a result of delay and accumulation in the blood and tissues of bile acids, a characteristic triad of symptoms arises: a severe skin itch, which causes patients to continuously comb the skin, relative bradycardia, symptoms of irritation of the central nervous system (irritability, increased excitability, shortness of breath, sleep disorder, sometimes hallucinations). The feces decolour, since bile does not enter the intestine, and has a clayey, gray-white color, and a laboratory test shows the absence of stercobilin in it. However, the bound (direct) water-soluble bilirubin in large quantities begins to excrete in the urine, giving it a brown color (in the figurative expression of the old authors, "the color of dark beer") with a bright yellow foam. Later, as a result of secondary damage (cholestatic hepatitis), the symptoms of hemorrhagic diathesis and the phenomenon of hepatic insufficiency are often associated.

Thus, focusing on this very important, visual and immediately attracting attention of the patient, the surrounding, and the doctor a diagnostic sign, you can distinguish two main clinical forms - icteric and jaundice.

[1], [2], [3], [4], [5], [6], [7], [8]

Symptoms of various forms of pancreatic cancer

The icteric form of the disease, as already noted, is more characteristic of carcinoma of the head of the pancreas, which compresses the common bile duct. However, with a small tumor and finding it outside the bile duct, jaundice may not develop. On the other hand, the swelling of the body and tail of the gland can germinate the head and cause jaundice. Usually even before the appearance of jaundice, there is already a slight decrease in the body weight of the patient.

An icteric form of adenocarcinoma occurs somewhat less often icteric (from 10 to 40% according to the data of different authors), mainly when the tumor is localized in the body and tail of the pancreas. Some patients have pain in the upper half of the abdomen day and night, others have persistent back pain, as mentioned above.

There is also a purely cachectic form of pancreatic cancer; while the patient may not feel pain, lies on the bed exhausted, refuses food, is indifferent to everything.

Very rare cases with prevalence of expressed psychopathic symptoms even in the early stage (depression, apathy or anxiety, delirium); sometimes such patients first enter a psychiatric hospital. Often, some signs of depression precede other symptoms of this disease. The syndrome of disturbance of higher nervous activity, like the inhibition of the food center, is attributed to one of the paraneoplastic reactions, the mechanism of which, unfortunately, has not yet been studied. Sometimes, with pancreatic cancer, there are signs of "pancreatic encephalopathy" - the aggressiveness of the patient, the change of excitations by depression, the appearance of visual and auditory hallucinations. In part, these psychogenic symptoms can also be caused by narcotic drugs that are administered to patients due to very severe cancers.

At objective research the tumor in depth of an epigastric area, dense, motionless is sometimes probed; in the last stage a solid tumor mass is detected. Such a tumor conglomerate by itself does not allow to accurately recognize the initial site of the lesion and distinguish it from the extensive fusion or developed tumor of neighboring organs - the stomach, colon, gallbladder, etc. Even with laparotomy, there are great difficulties; in 9% of the patients we observed after laparotomy, the cancer of the gland was not recognized; Similar difficulties can also occur in the prozector before careful dissection and analysis of the tumor mass.

With jaundice, there is an increase in the liver due to congestion of bile, and the presence of a bumpy liver is evidence of metastasis. Often an increase in the pear-shaped gallbladder is detected - a symptom of Courvosier (in 30-40% of cases and more); this feature serves as a difference between pancreatic cancer and cholelithiasis.

With cancer of the body and tail of the pancreas, in addition to painful pain, anorexia and weight loss as the main symptoms, thirst and polyuria can be observed (due to insulin apparatus insufficiency - pancreatic islet germination by tumor); in a number of cases, the tumor can be propolped. Jaundice for these tumor localizations is uncharacteristic, and if it occurs, then in the latest stages of the process, with the tumor growing all or almost the entire pancreas. However, as noted by many authors, often there are thromboses of vessels of various organs, and in some cases - multiple thrombosis. In this case, very significant shifts are observed in the blood coagulation system, which make possible the development of the syndrome of disseminated intravascular coagulation (DVS-syndrome), phlebothrombosis. The latter is especially often observed in pancreatic body cancer (in 56.2% of patients). Migrating venous thromboses, predominantly in the lower extremities, in the absence of other symptoms, are "alarming" for malignant tumors and primarily for the pancreas. It is suggested that tumor cells release thromboplastin, which in turn causes a compensatory increase in fibrinolysis. Thus, the mechanism of physiological hemostasis restores balance, but on the pathological level, which is easily broken from minor irritants. A distinctive feature of "cancer phlebothrombosis" is its resistance to therapy with anticoagulants.

Spontaneous bone fractures occur in individual patients due to metastasis of the tumor in the bone.

Splenomegaly develops in the case of cancerous growth of the spleen or portal vein, as well as in compression or thrombosis of it. Sometimes it is possible to listen to vascular noise from the left up from the navel as a manifestation of a splenic artery swelling.

Venous thromboembolism and thromboembolism are common in pancreatic cancer. Ascites serve as a late manifestation of the tumor.

According to research, pancreatic cancer has a variety of paraneoplastic symptoms. In some cases, these nonspecific symptoms may precede the appearance of obvious symptoms of pancreatic cancer.