The list is extensive, and it includes hepatitis, cirrhosis, hemolysis, enzyme deficiencies (e.g., Gilbert syndrome), drugs, sclerosing cholangitis, primary biliary cirrhosis, benign bile duct stricture (usually pancreatitis), choledocholithiasis, and periampullary tumors.

The exact origin of periampullary tumors is often difficult to determine using preoperative imaging studies.

Mr. Brown has decreased absorption of vitamin K secondary to biliary obstruction and the lack of bile salts for uptake of this fat-soluble vitamin. The INR should be corrected with parental vitamin K before any surgical procedure.

Both ultrasonography (US) and abdominal computed tomography (CT) will identify bile ductal dilation, a finding that distinguishes obstructive (choledocholithiasis, benign stricture, or periampullary tumors) from nonobstructive jaundice. US is recommended if choledocholithiasis is suspected (young patient age, intermittent abdominal pain). CT is recommended if cancer is suspected (old patient age, weight loss).

The most common symptoms of pancreatic cancer are abdominal pain, weight loss, jaundice, fatigue, back pain, anorexia, nausea, and vomiting. Glucose intolerance is present in most patients with pancreatic cancer. Patients with cancers of the head of the pancreas frequently notice jaundice and usually have less advanced cancers. In contrast, patients with cancers of the pancreas body and tail usually do not develop jaundice and almost always have advanced cancers.

Cancer of the pancreas remains a significant health problem in the United States and is the fourth leading cause of cancer-related death for both men and women. Approximately 30% of pancreatic cancer cases are related to cigarette smoking. The risk of developing pancreatic cancer increases with age. Although a few early studies suggested that coffee and excessive alcohol consumption could be risk factors, more recent studies have failed to demonstrate a risk. Diets high in meats, cholesterol, and nitrosamines may increase the risk. Several studies have suggested that diabetics have an increased risk. Some studies have reported an association between chronic pancreatitis and pancreatic cancer.

Familial predisposition is associated with 5% to 8% of all pancreatic cancer cases. Several hereditary conditions predispose individuals to pancreatic neoplasms. These syndromes include von Hippel-Lindau syndrome, hereditary nonpolyposis colon cancer, multiple endocrine neoplasia I, ataxia-telangiectasia, and familial atypical mole melanoma syndrome.

The two major goals of preoperative staging are (a) to identify metastases and (b) to determine whether the tumor is locally resectable with negative margins. Patients do not benefit from surgery if metastases are present or if the tumor cannot be completely removed with tumor-free margins. Thus, pretreatment imaging should identify patients who will not benefit from exploratory laparotomy. Only 10% to 15% of all patients with pancreatic cancer have resectable tumors.

After complete history and physical examination, abdominal CT is the single most important staging tool. CT identifies pancreatic masses, determines operability, and identifies metastases. Magnetic resonance imaging may provide similar information, but surgeons and radiologists have more experience with CT. Endoscopic retrograde cholangiopancreatography (ERCP) should not be performed for diagnostic purposes. Magnetic resonance cholangiopancreatography is a noninvasive test that provides equivalent information. ERCP may be useful for stent placement to palliate biliary obstruction for patients who are not candidates for surgical resection. Endoscopic US is a useful test that can identify small pancreatic masses not visible on CT. Endoscopic US also provides important information regarding tumor involvement of the superior mesenteric artery and vein. All patients should also have a chest radiograph.

Exclusion criteria for resection include (a) extrapancreatic disease (usually liver or peritoneal metastases), (b) tumor involvement of the superior mesenteric artery, and (c) occlusion of the superior mesenteric vein or portal vein.

Diagnostic needle biopsy of pancreatic masses can be successfully and safely performed with either CT or endoscopic US guidance. Despite early concerns, preoperative needle biopsy rarely results in seeding or peritoneal metastases. A patient with a resectable pancreatic mass and a double-duct sign generally does not require a preoperative needle biopsy. If preoperative chemoradiation is recommended for patients with borderline resectable tumors, needle biopsy is required before beginning treatment. Finally, some patients may desire tissue confirmation of malignancy before proceeding with surgery.