45. Cancer of the gallbladder and the biliary ducts

Cancer of the gallbladder and biliary ducts

Gallbladder carcinoma is usually adenocarcinoma and often presents late because early symptoms are nonspecific.
Risk factors include gallstones/chronic cholecystitis, porcelain gallbladder in selected contexts, chronic biliary inflammation, choledochal cysts and some congenital biliary abnormalities.
Cholangiocarcinoma arises from biliary epithelium and is classified as intrahepatic, perihilar (Klatskin tumour) or distal extrahepatic.
Risk factors for cholangiocarcinoma include primary sclerosing cholangitis, choledochal cysts, hepatolithiasis, liver flukes in endemic regions and chronic biliary inflammation.

Gallbladder cancer may invade liver directly and spread to regional nodes, peritoneum and distant organs.
Gallbladder cancer may present with RUQ pain, weight loss, anorexia, jaundice or a mass; it is sometimes discovered incidentally after cholecystectomy for presumed benign disease.
Cholangiocarcinoma causes progressive obstructive jaundice, pruritus, dark urine, pale stools, weight loss and cholangitis. Perihilar tumours obstruct hepatic ducts; distal tumours may mimic pancreatic head cancer.
Examination may reveal jaundice, hepatomegaly, cachexia, ascites or a palpable gallbladder depending on site and stage.

Liver function tests typically show a cholestatic pattern in obstructing lesions. CA 19-9 may support assessment but is not diagnostic and can rise with benign obstruction/cholangitis.
Ultrasound detects gallbladder masses, stones and duct dilatation. Multiphasic CT and MRI/MRCP define tumour extent, vascular involvement, ductal anatomy and metastases.
ERCP or percutaneous cholangiography may provide drainage and brush cytology/biopsy; EUS-guided sampling is useful for selected distal lesions or nodes.
Staging requires assessment of local invasion, vascular involvement, regional nodes and distant metastases. Tissue diagnosis is obtained when required before systemic therapy; resectability assessment should be made by a hepatobiliary multidisciplinary team.

Potentially resectable gallbladder cancer may require extended cholecystectomy with adjacent liver wedge/segments IVb/V and regional lymphadenectomy; bile duct resection is performed when needed for clear margins.
Resectable cholangiocarcinoma requires site-specific major surgery: liver resection for intrahepatic/perihilar disease or pancreaticoduodenectomy for selected distal tumours. These are complex operations with substantial morbidity.
Adjuvant systemic therapy may be offered after resection according to histology, margins and guidelines. Advanced disease is managed with biliary drainage, systemic chemotherapy/immunotherapy or targeted therapy where indicated, and symptom control.
Complications include cholangitis, liver failure, biliary leak, recurrence, cachexia and progressive obstruction. Prognosis depends strongly on stage and ability to achieve complete resection.