Cancer of the bile ducts: Cholangiocarcinoma
How the Bile Ducts work:
Bile a green-colored fluid produced by the liver cells. It collected within the bile ducts and transported to the gall bladder for storage. The bile from the liver mixes up with the food from the stomach and helps to absorb vitamins (like vitamin D and E) and required for the process of breaking down fats from our diet.
The presence of food within the first part of the small intestine (duodenum) stimulates the gall bladder to contract and squeeze bile out of the gall bladder, into the duodenum. Here it helps to digest and absorb the fats in the food.
Bile contains bile salts and bile pigments, most of which are recycled and the excessive ones are passed out of the body through urine and feces. The blockage of the bile duct system leads to dark urine and pale stools.
The human body made up of millions of cells. These cells different shapes and functions in different parts of the human body. The routine wear & tear of the body cells controlled by a process called the cell cycle. This process strictly regulated by the body’s control mechanisms. In cancers, the cells reproduce in an uncontrolled fashion which can lead to the formation of growth or tumor. The cancer cells develop the ability to invade and destroy surrounding cells by a process called invasion and eventually can spread to the other parts of the body (a process called metastases).
Some of the cells form a lump malignant (cancerous). others benign (non-cancerous). The cells which do not spread to other parts of the body (benign tumors) may cause symptoms as they grow by pressing on the surrounding organs. A lump diagnoses as benign or malignant with help of different investigations. such as blood tests, x-rays, ultrasound, and CT scans. Examination of the affected cells under a microscope can confirm the diagnosis of cancer. The special stains & techniques can also help to determine the origin of cancer.
Cancer that starts anywhere within the biliary system called cholangiocarcinoma. “Cholangio” means bile duct and “carcinoma” means cancer. Bile duct cancer is a very uncommon cancer and not much known about its cause. The presence of choledochal (bile duct) cysts, primary sclerosing cholangitis (a disease of the bile ducts within the liver), and gallstones leading to chronic bile duct irritation associated with the increased incidence of bile duct cancer. Bile duct cancer usually a slow-growing cancer and can spread to other parts of the body in the later stages of the disease. Its incidence of about 20 per million population and affects both men and women equally. Usually, it more common in people over 65 years of age. however recently young patients in their 4th decade of life are being diagnosed with bile duct cancer in Pakistan.
Symptoms of Bile Duct Cancer:
The general symptoms are non-specific and include weight loss, lethargy/tiredness, loss of appetite, indigestion, and abdominal pain.
Once cancer causes a blockage of the bile ducts symptoms to include pale feces, dark urine, itching, and jaundice.
Clinical evaluation by the doctor to look for the presence of jaundice (yellowness of skin and eyes) or presence of scar marks (due to itching) and presence of any lumps in the tummy.
Blood tests including LFTs (bilirubin level in your blood high due to the blockage of the bile duct).
Hemoglobin (Hb level) can below
Tumor markers. These are substances normally seen in the blood, however, in people with cancer, they may be high. In bile duct cancer, the tumor marker associated with it is Ca19.9.
MRI (magnetic resonance imaging)
Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
Endoscopic ultrasound (EUS)
You may undergo one or more of the scans in order to help identify the tumor and assess your suitability for the various treatments.
All of the previously mentioned tests may lead the doctor to diagnose bile duct cancer. However, the only definite way to confirm this diagnosis is to examine some of the abnormal tissue (cancer cells) under a microscope. Some cells may be taken during the ERCP procedure (these are called brushings). These cells taken to the laboratory for cytology examination. However, the results of cytology do not always produce a diagnosis and may give a negative result, despite cancer existing. If a larger sample of tissue required we may perform a biopsy. This when a needle passed through your skin, into the affected area. If your doctor planning to treat your cancer with surgery, you may not undergo a biopsy, as tissue confirmation can obtain after the operation, by the laboratory.
Complete surgical removal of the cancer is the mainstay of bile duct cancer treatment. The aim of the treatment to treat cancer and any symptoms it may cause. Treatment of the bile duct cancer depends on the stage of cancer and may differ from person to person because of:
Location of Cancer:
The bile duct cancer can occur anywhere within the bile duct system. There bile ducts throughout the liver – these called intra (within) hepatic (liver) bile ducts. some of which may run alongside major vessels that supply blood to or return blood from the liver.
There are also bile ducts that run from the liver to the gall bladder, and then from the gall bladder to the duodenum – these called extra (outside) hepatic ducts.
Size of Cancer:
The bile duct cancers can grow to a relatively large size causing any symptoms. Some cancers too small to identify scanning tests.
The spread of Cancer:
CT scans can detect whether cancer spread to any other part of the body – including the lymph glands. As the lymph system runs throughout the body, cancer that may have spread to the lymph system can increase the risk of further cancer spread (metastases) or increase the risk of cancer recurrence where main cancer already surgically removed.
Age of the patient:
Age can affect how well your body works, however, when deciding on which treatment the best for each individual. it important to assess each person’s actual health, rather than expected health for someone of that age.
Associated medical problems:
Are you well despite having another illness or does you have other medical problem limiting your lifestyle or life expectancy? Curable or palliative (may alleviate symptoms) therapies may offer to you, depending on the factors mentioned above. The clinical team caring for you will discuss, with you, the different treatments and therapies available. They will assist and support you in making decisions and choices about what is right for you.
Surgery may be offered as a potentially curable or palliative treatment. At present complete surgical removal of cancer offers the only possible cure.
Surgery to remove an intra-hepatic bile duct cancer will involve removing part of the liver.
A normal working liver can continue to function effectively. even if up to 80% of the liver removed. The part of the liver that would remain after surgery assessed to ensure that its functions normally. However, if the liver function compromised. removing even a small part of it may lead to liver failure and/or death.
Surgery to remove an extra-hepatic bile duct cancer may involve removing part or all of any tissue or organ next to it. As an example, if the cancer is within the gall bladder it may necessary to remove a small part of the liver, as the gall bladder is attached to the undersurface of the liver. If it near the lower part of the bile duct system, then part of the duodenum (small intestine) may need to remove. After surgery, patients monitored in a dedicated Liver Intensive Care Unit for 24-48 hours. After smooth ICU recovery, you will move to the award.
The insertion of a plastic or metal tube into the blocked bile duct, in order to keep it open, called stenting. It helps to restore the flow of bile into the intestine and can alleviate jaundice. The stent can be inserted by a procedure called Endoscopic Retrograde Cholangio-Pancreatogram (ERCP) and it’s done by gastroenterologists/ hepatologists. This a preferred way of stent placement as it is more convenient for the patient. In case of failed ERCP; the other way to insert the stent is called Percutaneous Transhepatic CholangioPancreatogram (PTC) and this procedure is done by specialist doctors called interventional radiologists
If the cancer-causing a narrowing of the small intestine (duodenum) this can cause problems with your ability to eat and drink and leads to vomiting after meals. A stent, larger than that used for the bile ducts. can use and inserted into the duodenum to allow you to eat and drink, without nausea and/or vomiting.
The treatment of cancer with drugs called chemotherapy). This treatment may offered as a palliative treatment, where surgery not possible, or as an add-on to surgical treatment. The aim of the palliative it to potentially slow down and/or shrink cancer. As an “add-on” (adjuvant) treatment, it is offered to treat any cancer that may remain after surgery. Each dose of chemotherapy (single or combination) is called a cycle, each cycle usually separated by 2-3 weeks of a recovery period. This allows your body to receive the treatment, react/respond, and recover.
Unfortunately, with bile duct cancer, it very difficult to predict whether it will respond to chemotherapy. However, in some people, even if response not achieved, they may find it can alleviate their symptoms and may prolong their life expectancy.
If after a detailed discussion of the treatment options you and your family decide rather not to receive any active treatment for your condition, or we feel that active treatment would not help you. the team will refer you for palliative care (supportive care to alleviate symptoms, not a curative treatment) near your home. Supportive care can also offered to you if you are undergoing treatment such as chemotherapy, which not expected to offer you a cure.
Mr. Touseef Ahmed
Transplant Coordinator: (for post-transplant follow up patients):
Hepatobiliary & Pancreatic Surgery Services:
Muhammad Asif 0341-0543883
Qaiser Rafiq John
24 Hours Patients emergency Helpline:
042 111 117 554