Arrange imaging and refer promptly when cancer is suspected

Progressive upper abdominal symptoms, jaundice or weight loss may need pancreas-protocol imaging and prompt referral. Jaundice with fever, rigors or systemic illness can require acute hospital assessment.

Guidance behind this advice

1. Recognise concerning presentations

Consider pancreatic disease with painless jaundice, persistent epigastric or mid-back pain, unexplained weight loss, steatorrhoea, persistent vomiting or unexplained pancreatitis. Review previous imaging and any duct or mass abnormality.

Assess jaundice with fever or rigors, sepsis, severe pain or dehydration urgently. Check FBC, liver tests, renal function and glucose/HbA1c, with lipase when indicated.

2. Choose appropriate imaging

Ultrasound is usually the first test in primary care, particularly when jaundice or biliary disease is part of the question. Its pick-up for pancreatic pathology is limited, so a normal or technically limited scan does not exclude a pancreatic problem.

If concern persists, discuss the case with our service so we can help select the next test; pancreas-protocol contrast CT, MRI/MRCP and EUS each answer different questions.

Tests for a suspected pancreatic problem
Test	Main use
Pancreas-protocol contrast CT	Assess a suspected mass and disease extent; discuss the protocol with radiology.
MRI/MRCP	Clarify ductal abnormalities and cystic lesions.
EUS	Assess small or indeterminate lesions and obtain tissue when it will guide treatment.
ERCP	Mainly therapeutic, including biliary drainage and selected sampling.

3. Separate surveillance and cyst assessment

Record affected relatives, ages at diagnosis and the actual genetic report. Strong familial clusters or relevant pathogenic variants need specialist genetics and pancreatic-risk assessment.

Eligible high-risk patients may have MRI/MRCP and EUS surveillance, often annually when findings are reassuring. Starting age and follow-up depend on the syndrome, family history and findings. Discuss fitness for possible treatment.

For an incidental cyst, review prior imaging, type, size, growth, duct calibre and any nodule or solid component. Jaundice, a mass or concerning duct changes warrants prompt referral.

4. Refer promptly and support the patient

Include symptom progression, weight and glucose trends, bilirubin, renal function, functional status and previous imaging reports. Coordinate biopsy and biliary drainage with the hepatopancreatobiliary team.

Address pain, nutrition and suspected pancreatic insufficiency while assessment proceeds. Confirm who will track imaging and referral completion; worsening symptoms need reassessment.

I am happy to discuss your patient's concerns with you and agree a personalised plan for the next investigation or referral.

Clinical pearls

CA19-9 may be normal with cancer or elevated with cholestasis; it is unsuitable for population screening.
A poorly visualised pancreas on ultrasound has not been adequately assessed.
New diabetes with unexplained weight loss deserves assessment of the accompanying symptoms and risk factors.

Pancreatic cancer: investigation and high-risk surveillance

Arrange imaging and refer promptly when cancer is suspected

1. Recognise concerning presentations

2. Choose appropriate imaging

3. Separate surveillance and cyst assessment

4. Refer promptly and support the patient

Clinical pearls

Information to share with your patient

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