In 2019, Pancreatic cancer became the third leading cause of cancer related mortality in the United States of America. Pancreatic cancer is a fatal malignancy that is predominantly seen in men with advanced age with aggressive course. Ninety percent of cases are adenocarcinoma. Pancreatic adenocarcinoma is very difficult to detect as is usually asymptomatic with no early signs. At least 80% of tumors are unresectable by the time of diagnosis. Despite substantial improvement in the survival rates for other major cancer forms, pancreatic cancer survival rates have remained relatively unchanged since 1960s. Multidisciplinary therapy with a combination of chemotherapy, radiation and surgery performed at high volume centers remains the best chance for cure. We report a rare case of a small T1 pancreatic head carcinoma with underlying chronic pancreatitis presenting with cancerous pericardial effusion and tamponade. Despite the small size of the primary tumor, the extensive pattern of lymphatic occlusion can lead to mesenteric and mediastinal lymphatic spread to the pericardium. US guided emergent pericardiocentesis was performed with removal of 750 cc of serosanguinous fluid. Cytopathological examination of the fluid revealed poorly differentiated pancreatic adenocarcinoma. A Port-A-Cath was placed, and he was referred to the oncology department to start chemotherapy.