Carcinoma of the bile ducts - Disorders of the gallbladder

Carcinoma of the bile ducts

Definition

Carcinomas of the bile ducts are called cholangiocarcinomas. They may be intrahepatic or extrahepatic.

Incidence/prevalence

Uncommon. Increasing in frequency in the West.

Age

Elderly

Aetiology/pathophysiology

Predisposed by chronic inflammation (e.g. primary sclerosing cholangitis associated with ulcerative colitis) and chronic infection with the parasitesClonorchis and Opisthorchis. Specific risk in patients with choledocal cysts. The tumour can arise anywhere in the biliary system and may be multifocal. It causes obstruction and hence dilatation of the proximal ducts.

Clinical features

The usual presentation is progressive obstructive jaundice. Other symptoms include vague epigastric or right upper quadrant pain, pruritus, anorexia and weight loss. Obstruction of the gallbladder may cause a mucocele or empyema presenting with biliary colic and a non-tender swelling in the right hypochondrium.

Macroscopy/microscopy

The carcinoma commonly appears as a sclerotic stricture anywhere along the biliary tree from the intrahepatic ducts down to the common bile duct. Histologically it is an adenocarcinoma.

Investigations

Ultrasound may show dilated intrahepatic ducts and a collapsed gallbladder.

Percutaneous transhepatic cholangiogram shows a stricture, may show multifocal disease.

CT scan may show hepatic metastases and nodal involvement.

Management

Curative treatment is only attempted if the tumour is localised and the patient is fit for radical resection.

Carcinoma of the common bile duct is treated by the Whipple’s operation.

Carcinoma of the upper biliary tract is only resectable

in 10% of patients. Hepatic resection is often advised. The remaining biliary tree is anastomosed to a Roux loop of jejunum.

Palliative treatments include insertion of a stent or anastomosis of a Roux loop of jejunum to a biliary duct in the left lobe of the liver.

Prognosis

The majority of patients die within 1 year of diagnosis. The prognosis is better for patients with carcinoma of the common bile duct who are suitable for a Whipple’s operation.