Gall bladder and bile duct cancer

What is gall bladder cancer?

Gall bladder (also spelt as gallbladder) is a small, pear-shaped organ on the right side of your abdomen, just beneath the liver. The gallbladder holds a digestive fluid called bile that's released into the small intestine. When cancer starts in gall bladder it is known as gallbladder cancer. Gallbladder cancer is a common cancer in India, especially in North India.

What are the symptoms of gallbladder cancer?

Symptoms of gallbladder cancer include:

• Yellowing of your skin and the whites of your eyes (jaundice)
• Intensely itchy skin
• White-colored stools
• Abdominal pain, especially in right side of abdomen
• A lump in the abdomen, especially on right side
• Unintended weight loss
• Fatigue

What are the risk factors for gallbladder cancer?

The following factors can raise a person's risk of developing gallbladder cancer:

• Gallstones: Gallstones are the most common risk factor for gallbladder cancer. These are rock-like formations of cholesterol and bile salts that can occur in the gallbladder or bile duct. Although gallstones are very common in general population, however, less than 1% of people with gallstones develop gallbladder cancer. It is unknown why some people develop cancer while most with gallstone disease do not.
• Gallbladder polyps: This type of polyp is a growth that sometimes forms when small gallstones get embedded in the gallbladder wall. Gallbladder polyps bulge inward from the inner gallbladder wall. Some polyps may also be caused by inflammation. Doctors often recommend gallbladder removal for people who have polyps larger than 1 centimeter because these are more likely to be cancerous.
• Age: Most people diagnosed with gallbladder cancer are older than 60 years.
• Gender: Women are about twice as likely to develop gallbladder cancer as men.
• Smoking: Tobacco use may increase the risk of gallbladder cancer.
• Family history: A family history of gallbladder cancer slightly increases a person’s risk of developing gallbladder cancer.

How is gallbladder cancer diagnosed?

The common tests used to diagnose gallbladder cancer include:

• Liver function tests: Blood tests to measure your liver function can give your doctor clues about what's causing your signs and symptoms.
• Tumor marker test: Checking the level of cancer antigen (CA) 19-9 in your blood may give your doctor additional clues about your diagnosis. CA 19-9 is a protein that's overproduced by bile duct and gallbladder cancer cells. High level of CA 19-9 in your blood doesn't mean you have cancer, though. This result can also occur in other bile duct diseases, such as bile duct inflammation and obstruction.
• Endoscopic ultrasound (EUS): This is a special type of endoscope that has a tine ultrasound probe fitted on its tip. When this endoscope is passed to the stomach or duodenum (small intestine), it gives very accurate images of the gallbladder. If any thickening or tumor is found in the gallbladder, fine needle aspiration cytology (FNAC) can be done with the help of EUS. 
• Imaging tests: Imaging tests can help your doctor see any abnormalities in your internal organs that may indicate gallbladder cancer. Techniques used to diagnose gallbladder cancer include computerized tomography (CT) scans and magnetic resonance imaging (MRI) combined with magnetic resonance cholangiopancreatography (MRCP). MRCP is increasingly being used as a noninvasive alternative to ERCP. It offers 3-D images without the need for a dye to enhance the images.
• Biopsy: A biopsy is a procedure to remove a small sample of tissue for examination under a microscope. Your doctor may use an imaging test, such as an endoscopic ultrasound or CT scan, to guide the needle to the precise area of gallbladder where cancer is suspected.

If your doctor confirms a diagnosis of gallbladder cancer, he or she tries to determine the extent (stage) of the cancer. Often this involves additional imaging tests. Your cancer's stage helps determine your prognosis and your treatment options.

How is gallbladder cancer treated?

Gallbladder cancer may be treated with one or more treatments, including surgery, chemotherapy, or radiation therapy. If detected at an early stage, gallbladder cancer has a much higher chance of being successfully treated.

What is bile duct cancer?

Bile ducts are the slender tubes that carry the digestive fluid bile and connect your liver to your gallbladder and to your small intestine. When cancer starts from the bile ducts it is known as bile duct cancer, also known as Cholangiocarcinoma. It is an uncommon form of cancer that occurs mostly in people older than age 50, though it can occur at any age.Cholangiocarcinoma is a type of tumor that is very difficult to treat.

What are the types of bile duct cancer?

Doctors divide bile duct cancer or cholangiocarcinoma into different types based on where the cancer occurs in the bile ducts:

• Intrahepatic cholangiocarcinoma occurs in the parts of the bile ducts within the liver and is sometimes classified as a type of liver cancer.
• Hilarcholangiocarcinoma occurs in the bile ducts just outside of the liver. This type is also called perihilarcholangiocarcinoma.
• Distal cholangiocarcinoma occurs in the portion of the bile duct nearest the small intestine.

What are the symptoms of bile duct cancer?

Symptoms of cholangiocarcinoma include:

• Yellowing of your skin and the whites of your eyes (jaundice)
• Intensely itchy skin
• White-colored stools
• Fatigue
• Abdominal pain
• Unintended weight loss

What are the risk factors of bile duct cancer?

Factors that may increase your risk of cholangiocarcinoma include:

• Primary sclerosing cholangitis: This disease causes hardening and scarring of the bile ducts.
• Chronic liver disease: Scarring of the liver caused by a history of chronic liver disease increases the risk of cholangiocarcinoma.
• Bile duct problems present at birth: People born with a choledochal cyst, which causes dilated and irregular bile ducts, have an increased risk of cholangiocarcinoma.
• A liver parasite: In areas of Southeast Asia, cholangiocarcinoma is associated with liver fluke infection, which can occur from eating raw or undercooked fish.
• Older age:Cholangiocarcinoma occurs most often in adults over age 50.
• Smoking: Smoking is associated with an increased risk of cholangiocarcinoma.

How is bile duct cancer diagnosed?

If your doctor suspects cholangiocarcinoma, he or she may have you undergo one or more of the following tests:

• Liver function tests: Blood tests to measure your liver function can give your doctor clues about what's causing your signs and symptoms.
• Tumor marker test: Checking the level of cancer antigen (CA) 19-9 in your blood may give your doctor additional clues about your diagnosis. CA 19-9 is a protein that's overproduced by bile duct cancer cells. High level of CA 19-9 in your blood doesn't mean you have bile duct cancer, though. This result can also occur in other bile duct diseases, such as bile duct inflammation and obstruction.
• Endoscopic ultrasound (EUS): This is a special type of endoscope that has a tine ultrasound probe fitted on its tip. When this endoscope is passed to the stomach or duodenum (small intestine), it gives very accurate images of the bile duct. If any thickening or tumor is found in the bile duct, fine needle aspiration cytology (FNAC) can be done with the help of EUS.
• Imaging tests: Imaging tests can help your doctor see any abnormalities in your internal organs that may indicate cholangiocarcinoma. Techniques used to diagnose bile duct cancer include computerized tomography (CT) scans and magnetic resonance imaging (MRI) combined with magnetic resonance cholangiopancreatography (MRCP). MRCP is increasingly being used as a noninvasive alternative to ERCP. It offers 3-D images without the need for a dye to enhance the images.
• Biopsy:A biopsy is a procedure to remove a small sample of tissue for examination under a microscope.If the suspicious area is located very near where the bile duct joins the small intestine, your doctor may obtain a biopsy sample during ERCP. If the suspicious area is within or near the liver, your doctor may obtain a tissue sample by inserting a long needle through your skin to the affected area (fine-needle aspiration). He or she may use an imaging test, such as an endoscopic ultrasound or CT scan, to guide the needle to the precise area.

If your doctor confirms a diagnosis of cholangiocarcinoma, he or she tries to determine the extent (stage) of the cancer. Often this involves additional imaging tests. Your cancer's stage helps determine your prognosis and your treatment options.

What are the treatment options for cholangiocarcinoma (bile duct cancer)?

The treatment options for cholangiocarcinoma may include:

Biliary drainage: Biliary drainage is a procedure to restore the flow of bile. Biliary drainage helps relieve signs and symptoms of cholangiocarcinoma. However, biliary drainage does not cure cholangiocarcinoma, it just relieves the symptoms of jaundice and itching. Biliary drainage can involve bypass surgery to reroute the bile around the cancer or stents to hold open a bile duct being collapsed by cancer. The stents are placed into the biliary system either endoscopically or via the percutaneous method. The endoscopic method is known as ERCP or Endoscopic Retrograde Cholangio-Pancreatography. The percutaneous method is known as PTBD or Percutaneous transhepatic biliary drainage.

Surgery: Whenever possible, doctors try to remove as much of the cancer as they can. For very small bile duct cancers, this involves removing part of the bile duct and joining the cut ends. For more-advanced bile duct cancers, nearby liver tissue, pancreas tissue or lymph nodes may be removed as well.

Liver transplant: Surgery to remove your liver and replace it with one from a donor (liver transplant) may be an option in certain cases for people with hilarcholangiocarcinoma. For many, a liver transplant is a cure for hilarcholangiocarcinoma, but there is a risk that the cancer will recur after a liver transplant.

Chemotherapy: Chemotherapy uses drugs to kill cancer cells. Chemotherapy may be used before a liver transplant. It may also be an option for people with advanced cholangiocarcinoma to help slow the disease and relieve signs and symptoms.

Radiation therapy: Radiation therapy uses high-energy sources, such as photons (x-rays) and protons, to damage or destroy cancer cells. Radiation therapy can involve a machine that directs radiation beams at your body (external beam radiation). Or it can involve placing radioactive material inside your body near the site of your cancer (brachytherapy).

Photodynamic therapy: In photodynamic therapy, a light-sensitive chemical is injected into a vein and accumulates in the fast-growing cancer cells. Laser light directed at the cancer causes a chemical reaction in the cancer cells, killing them. You'll typically need multiple treatments. Photodynamic therapy can help relieve your signs and symptoms, and it may also slow cancer growth. You'll need to avoid sun exposure after treatments.