Symptoms

Cancer of the pancreas is sometimes called a “silent” disease because symptoms are not usually present in early stages. Many patients have advanced disease by the time it becomes noticeable to the patient and doctors. If symptoms are present, they are often vague. Patients may experience different symptoms depending on the location, type and stage of the tumor. Symptoms that commonly lead to diagnosis include: jaundice, abdominal and/or back pain, diabetes, unexplained weight loss and loss of appetite. A person with advanced pancreatic cancer may also experience ascites and blood clots. Symptoms such as fatigue, weakness, digestive difficulties and depression may occur at any time.

 

Read below for more information about each symptom commonly associated with pancreatic cancer. If someone experiences one or more of the symptoms mentioned in this section, it does not mean that he or she has pancreatic cancer. There are other common medical problems or conditions that may also cause these or similar symptoms. Therefore, anyone experiencing these symptoms should consult with a doctor. Only a doctor can diagnose the cause of an individual’s symptoms.

Jaundice

It is common for people with pancreatic cancer to experience jaundice, a yellowing of the skin and eyes caused by the buildup of bilirubin in the blood.  People experiencing jaundice may also have itchiness of the skin, abnormally dark urine and clay-colored stools.

 

Possible Causes of Jaundice
Like other cells in the body, red blood cells die and break down after a normal life span, typically 110-120 days.  Bilirubin is a breakdown product of hemoglobin, a component of red blood cells.  Bilirubin is then excreted or removed from the body in bile.  Bile is a digestive fluid that flows from the gall bladder through the common bile duct and into the duodenum, part of the small intestine.  Sometimes, pancreatic tumors or inflammation of the pancreas will block the bile duct where it runs through the head of the pancreas.  This obstruction prevents bile from flowing properly and causes the buildup of bilirubin in the blood known as obstructive jaundice.  Jaundice may occur when the bilirubin level in the blood is greater than 2.5 mg/dl.

Obstructive jaundice develops in 70-90% of people with pancreatic cancer and may result in complications, such as the inability to properly absorb nutrients, coagulopathy (a defect in the blood clotting mechanism), pruritus (itching sensation of the skin) and cholangitis (inflammation of the bile duct).

 

Treatment Options
One strategy for alleviating obstructive jaundice is placement of a biliary stent to keep the bile duct open and to allow for proper flow of bile.  A biliary stent is a small tube made of plastic or metal that is placed in the bile duct at the location of the obstruction.  A stent made of plastic is typically used for temporary or short-term relief of obstructive jaundice.

 

Plastic Stents
Placement of a plastic stent can relieve jaundice and allow for improved nutrition for an individual who will undergo surgery to remove the pancreatic tumor in the near future.  Plastic stents can become occluded, or blocked, more quickly than metal stents.  However, plastic stents can be removed and replaced if they become blocked.  In general, plastic stents will remain open between a few weeks and a few months.

 

Metal Stents
An expandable metal stent is typically used for more long-term relief of obstructive jaundice in people whose tumors are not able to be surgically removed.  Metal stents tend to remain open longer than plastic stents.  If a metal stent does become blocked, it will not likely be removed.  Rather, a new stent will be placed inside of the blocked stent to re-open the bile duct.  Metal stents will generally remain open from several months to over a year.

 

Biliary Stent Placement
Stent placement is performed endoscopically by a gastroenterologist during a procedure called endoscopic retrograde cholangiopancreatography (ERCP).  The patient will be required to fast (no eating or drinking) for six hours prior to the procedure.  In preparation for the procedure, most patients will receive monitored anesthesia.  An endoscope, or lighted tube, is passed down the throat and through the stomach to the area of the bile duct.  When the gastroenterologist locates the area of obstruction, the stent will be placed.

Occasionally, the procedure can be performed in an outpatient setting.  Sometimes, the patient will need to spend one night in the hospital so that the physician can monitor him or her for any complications or reactions.

 

Possible Complications of Stent Placement
The most common complication during biliary stent placement is inability to place the stent due to the size of the tumor or the shape of the bile duct.  Less common complications include perforation (tearing) of the bile duct and bleeding.

It is possible for an infection to develop around a stent.  Fever or a return of jaundice may indicate infection and require emergency treatment.  Anyone who suspects infection due to blockage of a stent should contact his or her doctor or the emergency room immediately.

Controlling Weight Loss

Weight loss is a common problem in individuals with cancer of the pancreas and/or after a Whipple procedure, the most common surgery for pancreatic cancer.  Weight loss can be associated with treatment or with the cancer itself. 

 

What is tumor-induced weight loss? 

Tumor-induced weight loss, also known as cancer cachexia, is a complex problem that affects the way calories and protein are used in the body.  Cancer cachexia can cause the body to burn more calories than usual, break down muscle protein and at the same time decrease appetite.

Most pancreatic tumors release compounds called cytokines into the blood.  These cytokines change the body’s use of nutrients (proteins, carbohydrates and fats).  In addition, cytokines cause the body to burn calories faster than they are replaced.  The body’s appetite is then suppressed causing decreased food intake.  This process leads to thinner bodies, smaller muscles and fatigue.  Weight loss and malnutrition can have a significant impact on quality of life, daily functioning, response to treatment, length of hospital stays and complications such as infections.

 

What steps can I take to minimize tumor-induced weight loss?

Though we are gaining knowledge about cancer cachexia, little is known about how to control or stop the process.  Nutrition counseling, use of oral nutrition supplements and use of appetite-stimulating medications may help patients with tumor-induced weight loss.  Controlling tumor growth through treatment such as chemotherapy or chemoradiation therapy can also assist in controlling weight loss.

MCT (Medium Chain Triglyceride) oil is a nutrient which may help control weight loss in patients with uncontrolled malabsorption.  MCT oil is a calorie-rich type of fat that is rapidly absorbed by the body.  It is found naturally in coconut oil, palm kernel oil and butter.  MCT oil is added to some medical nutritional supplements and can be purchased alone as a nutritional supplement.  Use of oral nutritional supplements may promote weight gain, help increase strength and physical activity and improve quality of life.  A doctor or registered dietitian should advise the patient about taking MCT oil, the source and the amount.

 

The following tips may assist in controlling weight loss:

  • Consult with a registered dietitian for nutrition counseling.
  • Get plenty of rest.
  • Plan to eat 5-6 times per day including snacks in between meals.
  • Eat calorie-rich, nutrient-dense foods and try not to consume foods or liquids with little nutritional value, like soft drinks.
  • Restrict or avoid any foods that may cause or worsen diarrhea.
  • Use medical nutritional products, such as Boost®, Ensure® and Carnation® Instant Breakfast®, as snacks or drink with medications that can be taken with food.
  • Consider use of pancreatic enzymes and take them as directed.
  • Check with the doctor to see if medications would be helpful in controlling weight loss.
  • Maintain adequate hydration.
  • Incorporate physical activity into your day as it supports lean body mass, may enhance appetite and may decrease fatigue:
    • Aim for a total of 30 minutes per day of activity, such as walking.
    • Break activity into small increments of 5-10 minutes totaling 30 minutes per day.

Pain

Pain in the upper abdomen or mid-back may be caused by the tumor involving or invading nerves or organs that lie near the pancreas. Pain can also be caused if the tumor causes a blockage in the digestive tract. Treatment, including pain medications and procedures such as a celiac plexus nerve-block (see below), can be important in managing pancreatic cancer pain. Since most pain medications lead to constipation which can make the pain much worse, a doctor can prescribe medications to avoid constipation.

 

What is a celiac plexus block?
A celiac plexus block is a procedure that damages the celiac nerves with the intent to ease pain. It is sometimes used to treat abdominal pain in pancreatic cancer. The celiac plexus block procedure damages these nerves for 3-6 months until they repair themselves.

 

Why use a celiac plexus block?
Patients with advanced pancreatic cancer often experience severe abdominal pain. They often require strong pain medications, such as opioids, to manage this pain. However, pain medications can cause uncomfortable side effects, such as constipation. A celiac plexus block may be considered if:

  • pain medication produces unmanageable side effects, or
  • pain is uncontrollable with pain medication.


Often, patients with advanced pancreatic cancer experience breakthrough pain. Breakthrough pain is an intense period of pain experienced even when medication to control more constant pain is in use. Medications are available to treat breakthrough pain, but this method of treatment is not always effective. A celiac plexus block can help a patient avoid breakthrough pain, but generally does not eliminate all pain. A celiac plexus block may reduce the need to use pain medications and may alleviate many of the unwanted side effects that may accompany opioid use.

The block may not help patients whose pain is not radiating from the bundle of nerves in the upper abdomen. A doctor or nurse would help make this determination.

 

What happens during a celiac plexus block and who performs the procedure?
A celiac plexus block can be performed during surgery, during an endoscopic ultrasound (EUS) or by going through the skin, called a percutaneous approach. In all cases, a doctor will first inject a painkiller (anesthetic) to numb the celiac nerves followed by a substance to damage the nerves. The effects of the anesthetic are almost instantaneous, but are not long-lasting. The nerve killing, or neurolytic, substance is usually an alcohol or a steroid and may take up to one week to be fully effective. In many cases, a few minutes pass between the two injections. Sometimes, the doctor will perform a trial block with the anesthetic medication 8-72 hours prior to the actual block using the neurolytic substance.

 

Surgical Approach
If a patient is able to undergo surgery for pancreatic cancer, the pancreatic or gastrointestinal surgeon will operate with the intent to remove the pancreatic tumor. If, after opening the abdomen, the surgeon determines that the tumor is cannot be surgically removed, a nerve block may be performed to help manage pain that may be caused by the tumor.


EUS Approach
Endoscopic ultrasound (EUS) is a procedure used to image the digestive tract, including the pancreas. An endoscope is passed through the patient’s mouth into the stomach and the top part of the small intestine. Then, ultrasound is used to create images of the pancreas. Just before an EUS, the patient will receive sedative medication through a vein in the arm and local anesthetic spray to the throat, in order to be comfortable during the procedure. Since sedative medications are used, the patient should prepare in advance to have someone else drive him/her home after the procedure.

A patient may have an EUS specifically so the doctor can perform a celiac plexus block or the patient may already be scheduled for an EUS for other reasons. A patient who is scheduled to have an EUS procedure and who experiences uncontrolled pain should discuss the celiac plexus block option with the gastroenterologist prior to the procedure.


Percutaneous Approach
During a percutaneous celiac plexus block, the celiac nerves are accessed by inserting a needle through the skin. In this case, an anesthesiologist who specializes in pain management typically inserts the needle through the back.

First, an IV is inserted into the arm to provide the patient with pain relief and hydration throughout the procedure. Then, the patient lies face down on an x-ray table. An area of the patient’s back is cleansed and numbed with a local anesthetic. A dye is injected and an x-ray or computed tomography (CT) scan image helps the doctor guide the needle to the correct location. Then, the anesthetic is injected into the celiac nerve bundle followed by the neurolytic substance.


How long does the celiac plexus block procedure take?
The celiac plexus block itself takes 30-60 minutes. However, the actual time required depends on which method is used to access the celiac nerve bundle.


What happens when the celiac plexus block is finished?
When the celiac plexus block is completed, the celiac nerves are unable to send pain messages to the brain. Most patients feel some, though not total, relief from pain after the procedure. Since the nerve block typically lasts 6-9 months, the procedure may need to be repeated.

 

What are the possible side effects?

Complications related to a celiac plexus block can be serious and severe. A celiac plexus block is not recommended for patients taking blood-thinning medication or who have an infection or bowel obstruction. Talk at length with your healthcare team about the benefits and risks of a celiac plexus block to determine if it is the right procedure to manage your pain.

  • Low blood pressure (hypotension) along with a feeling of warmth in the legs immediately following the procedure
  • Diarrhea
  • Pain in the area of the injection (tenderness, swelling, bruising)
  • Muscle spasm at the area of injection

 

Less Common Side Effects:

  • Delayed gastric emptying and diarrhea if the anesthetic or neurolytic substances spread and affect the nerves that assist in bowel function
  • Damage to kidneys
  • Paralysis if the fluid used to destroy the celiac nerve spreads into the spinal or epidural space
  • Accidental injection into the blood vessels causing a seizure or reduced blood supply to the spinal cord
  • Seizure caused by accidental injection into the blood vessels
  • Allergic reaction to the dye or medications injected
  • Accidental puncture of an organ
  • Infection (increased redness or swelling) at the injection or IV site

 

Cancer Pain Resources

Pain.com

Cancer-Pain.org
Association of Cancer Online Resources

Partners Against Pain

 

Digestive Difficulties

Common digestive difficulties associated with pancreatic cancer include poor appetite, indigestion and nausea. Some or all of these symptoms may occur when a tumor in the pancreas presses against the stomach or first portion of the small intestine, known as the duodenum. If this happens, food may remain in the stomach and cause several digestive difficulties, including nausea and vomiting. Digestive symptoms can also occur due to blockage of the pancreatic duct through which the pancreatic enzymes flow or due to changes in the amount of pancreatic enzymes produced. Various changes in diet, pancreatic enzyme products and other treatments can help to alleviate many digestive symptoms.

Blood Clots

Deep vein thrombosis (DVT) is a potentially serious condition where blood clots form in the veins, usually in the legs. Cancer causes changes in the blood that can increase the likelihood of forming clots. Blood clots may go unnoticed and cause no symptoms. However, they are often associated with swelling, pain and tenderness in the affected area. Swelling in one leg only is often a sign of DVT. A fragment of the clot may break loose and travel to the lungs, causing damage to the lung tissue from the sudden decrease in blood supply. This is called a pulmonary embolism and is a serious condition. DVT is commonly treated with drugs called anticoagulants that thin the blood and prevent existing clots from getting larger and new clots from forming.

Diabetes & Pancreatic Cancer

Approximately 25.8 million people in the United States, approximately 8.3% of the population, have diabetes. It is estimated that 18.8 million have been diagnosed, but unfortunately, 7.0 million people, or over one fourth, are unaware that they have the disease.

 

What is diabetes?
Diabetes is a disease in which the body does not make or properly use a pancreatic hormone called insulin. Insulin helps the body utilize glucose (sugar) efficiently. Normally, insulin allows glucose to enter cells to be used for energy. In people with diabetes, either the body does not produce enough insulin or the amount that is produced is not fully effective. Instead of entering cells, the glucose remains in the blood resulting in high blood glucose levels. High blood glucose can lead to cell damage and long-term complications. Diabetes can cause major health problems, such as high-blood pressure, blindness, kidney disease and neuropathy.

There are several types of diabetes. Type 1 diabetes results from the body’s inability to produce insulin and accounts for approximately 5% of those diagnosed with the disease. Type 2 diabetes results from the body’s failure to properly use insulin combined with insulin deficiency and accounts for most diagnosed cases of diabetes in the United States. Pre-diabetes occurs when a person’s blood glucose levels are higher than normal, but are not high enough to be diagnosed as type 2 diabetes. Approximately 79 million Americans are pre-diabetic. Other types of diabetes result from specific genetic conditions, surgery, medications, infections, pancreatic diseases and other illnesses.

 

How does diabetes relate to pancreatic cancer?
Diabetes may be either a risk factor or a symptom of pancreatic cancer. Pancreatic cancer is two times more likely to occur in people who have diabetes than in people who do not have diabetes. In pancreatic cancer patients who have had diabetes for less than five years, it is unclear if the diabetes contributed to the cancer or if the precancerous cells caused the diabetes.

Also, research has shown that recent onset of diabetes in people over 50 or a sudden change in blood sugar control in those who are already diabetic may be a symptom of pancreatic cancer.

 

What foods may help control diabetes?
People with diabetes and cancer have special nutritional needs. An individual can have a positive influence on his/her blood glucose and overall health by choosing foods wisely. By eating well-balanced meals in the correct amounts, individuals can keep their blood glucose level as close to normal (non-diabetes level) as possible. The proper balance of nutrients from food, medication, physical activity and nutritional supplements are needed to improve blood glucose control, physical healing, weight maintenance and quality of life. No single food will supply all the nutrients a body needs, so good nutrition means eating a variety of foods.

It is important to eat foods from each group at each meal every day. Foods are divided into five main groups:

  • Fruits and vegetables (oranges, apples, bananas, carrots and spinach)
  • Whole grains, cereals, and bread (wheat, rice, oats, bran and barley)
  • Dairy products (milk, cheese and yogurt)
  • Meats and meat substitutes (fish, poultry, eggs, dried beans and nuts)
  • Fats and oils (oil, butter and margarine)

By eating foods from each food group at every meal, an individual is likely to consume a proper balance of all the nutrients (carbohydrates, proteins, fats, vitamins and minerals) that the body needs to function. Eating meals and snacks at regular times is also necessary for controlling blood sugar levels.

The body uses calories from carbohydrates for energy and uses protein to build lean body mass. Choosing foods with complex carbohydrates, such as starch and fiber, may help in the control of blood glucose levels. Fiber present in plant-based foods can help lower blood glucose and cholesterol levels. Foods high in fiber include: bran cereals, cooked beans and peas, whole-grain bread, fruits and vegetables. Eating high-protein foods at each meal and snack also may help in the control of blood sugar. Healthy choices are dried beans, peas, lentils, lean meats and low-fat dairy products.

Including small amounts of healthy fat may also help control blood sugar levels. Foods high in healthy fats include: olive, canola and peanut oils, olives, avocados, nuts and seeds and fatty fish such as mackerel, lake trout, herring, sardines, albacore tuna and salmon.

 

Should diabetics with pancreatic cancer avoid eating all sugar?
No, unless this is the advice of a physician or dietitian. Cutting all forms of sugar out of the diet will not result in the death of cancer cells because cancer cells cannot be starved. Glucose is the basic food source for all cells, including cancer cells and is provided by eating foods containing carbohydrates. It may be necessary to avoid foods high in simple sugars if the individual experiences problems with watery diarrhea after eating such foods. Foods high in simple sugars include rich desserts, ice cream, candy, sweetened drinks and fruits packed in syrup.

If the patient is experiencing weight loss unrelated to blood sugar control, it may be caused by cancer induced weight loss, called cancer cachexia. In this situation, chemical changes in the body cause the breakdown of body fat and lean body mass to make energy for cancer and healthy cells. It may be necessary to introduce another supplement into the diet. Consult your doctor or dietitian to find out which supplement is right for you.

 

Who can help me create an appropriate diet?
If you or a loved one has pancreatic cancer and diabetes, consider consulting a registered dietitian (RD) who understands these two conditions. A registered dietitian has expertise in how the body uses food and can teach you how the food you eat affects blood glucose level and how to coordinate diabetes medications and meal schedules. A registered dietitian can also provide guidance about nutritional supplements that may be helpful for patients experiencing weight loss related to the cancer.

Please consult with a physician for direction on the proper management of diabetes.

 

Other Resources:
American Diabetes Association

Ascites

What is ascites?
Ascites (pronounced ah-site-eez) is the accumulation of excessive fluid in the abdominal lining, called the peritoneum.  This extra fluid causes the belly to become swollen and distended.  Cancer accounts for approximately 10% of all cases of ascites and can occur when cancer has spread to the peritoneum from its original site.  Most cases of cancer-related ascites occur in individuals with cancers of the breast, ovaries, colon, stomach or pancreas.  It is especially common in individuals with advanced metastatic pancreatic cancer.

 

Possible Causes of Ascites

  • If the cancer has spread to the peritoneum in the abdomen, the lining can become irritated.  To soothe this inflammation, the peritoneum produces fluid which becomes trapped within the abdomen.  As the fluid accumulates, the abdomen swells.
  • If the cancer has spread to the liver or the portal vein leading to the liver, blood pressure can rise within the liver impairing circulation and lead a build-up of fluid in the abdomen.
  • If the liver is damaged it may produce less blood protein, which disrupts the body’s fluid balance, causing fluids to collect in body tissues including the abdomen.
  • If the cancer blocks the lymphatic system, excess fluid is unable to be efficiently drained and results in fluid build-up in the abdomen.

Signs and Symptoms of Ascites
Small amounts of fluid in the abdomen usually produce no symptoms.  However, as the amount of fluid increases, the abdomen swells, the skin stretches tightly across the abdomen and the navel becomes flat or even pushed out.  This puts pressure on the stomach and lungs and can lead to other symptoms.  The following may be signs and symptoms of ascites:

  • Abdominal swelling, discomfort and increased waist size
  • Difficulty breathing and shortness of breath
  • Decreased appetite and a sense of fullness
  • Abdominal pressure or pain
  • Indigestion
  • Weight gain
  • Fatigue
  • Constipation
  • Nausea
  • Ankle swelling

Tell your doctor or another member of your healthcare team if you develop these problems or if you have been treated for ascites and these symptoms have returned.

 

Treatments for Ascites 
The accumulation of fluid in the abdomen can be controlled for most patients in several ways:

 

Treating the Tumor – Effective treatment of the cancer through chemotherapy or surgery may reduce the fluid build-up in the abdomen.

 

Diuretics – Diuretics are drugs that make the kidneys excrete more water into the urine which can reduce fluid build-up in the abdomen.

 

Paracentesis – In moderate to severe cases of ascites, the fluid can be drained to relieve discomfort with a procedure called paracentesis.  Paracentesis involves inserting a needle attached to a tube into the abdominal cavity and slowly draining the excess fluid.  The length of time required to remove the excess fluid varies depending on the amount that needs to be removed.  Sometimes a small amount of fluid can be drained in an outpatient setting with no hospital stay required.  However, if a large amount of fluid needs to be removed, the patient may need to be hospitalized for the procedure.

Undergoing paracentesis can temporarily reduce symptoms, but the excess fluid in the abdomen tends to return at which time paracentesis may be repeated.  Some patients who produce large amounts of fluid build-up may benefit from the insertion of a catheter that drains the ascites continuously.

 

Comfort Measures – While paracentesis can reduce symptoms for a period of time, fluid build-up typically returns and patient care should focus on measures to facilitate fluid loss and decrease symptoms.  Common problems with recurrent ascites are the swelling of the legs, breathing difficulty, and blockage of the intestine.  Resting in a reclined position with the feet elevated alleviates pressure on the internal organs, improves blood flow returning from the lower extremities, and increases fluid loss.

 

Because the accumulated fluid is often very heavy, it can impair movement within the bowel.  Therefore, it is important to prevent or manage constipation, especially in a patient who is taking opioids for pain management or has other risks for constipation.  Ascites can also slow the movement of food leaving the stomach leading to nausea and vomiting.  Proper positioning may help nausea as the stomach empties toward the right and many patients are less prone to nausea when lying on their right side.  In addition, medications that promote upper gastrointestinal movement are also helpful for alleviating this problem.  Patients should consult with the doctor to prevent and manage symptoms.

 

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