Bile Duct Cancer Symptoms, Stages and Treatment

The lesion's location is determined from the patient's medical findings and imaging examinations. Transabdominal ultrasound is generally performed to assess jaundice. For a patient with suspected bile duct cancer who has not undergone imaging (a patient with elevated blood CA19-9), the initial imaging test is contrast-enhanced magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP) or multiphasic contrast-enhanced multidetector-row computed tomography (MDCT). Magnetic resonance imaging (MR) and computed tomography (CT) are also imaging tests used for diagnosis. Biopsy, fine-needle aspiration or brush cytology of the bile ducts are other diagnostic methods that should be performed. Physical Examination Most patients with extrahepatic bile duct cancer have jaundice; some may have liver enlargement (hepatomegaly), a right upper quadrant mass or fever. The gallbladder is rarely palpable. If it is palpable in a patient with jaundice, this is considered more suggestive of a malignant tumour (pancreatic or biliary) than other causes of bile duct obstruction. However, this rule has exceptions (chronic pancreatitis, parasitic biliary obstruction, congenital (hereditary) choledochal cyst, and commonly encountered hepatic duct obstruction near the cystic duct). Therefore, physical examination findings have limited value for establishing a diagnosis. Laboratory Tests Blood Tests No blood test can diagnose bile duct cancer (cholangiocarcinoma) by itself. Blood bilirubin, alkaline phosphatase and gamma-glutamyl transferase levels are generally elevated, while transaminase levels (ALT, AST), called liver function tests, may be normal. These laboratory findings indicate that jaundice arises from bile duct obstruction rather than liver parenchymal infection or inflammation. CA19-9 is also generally elevated in bile duct cancer. However, it is not a screening tool sensitive enough to yield clear results. Nevertheless, when assessed together with imaging, it may help diagnose bile duct cancer. Imaging Tests Extrahepatic bile duct cancers may not be directly visible, particularly if the tumour is small. However, indirect signs (duct dilation) may contribute to diagnosis. If no gallstones are detected, duct dilation (>6mm in normal adults) is thought to result from an obstructing malignant lesion. Distal lesions dilate both intrahepatic and extrahepatic ducts, while proximal (near) extrahepatic lesions may dilate only intrahepatic ducts. Abdominal Ultrasound Transabdominal ultrasound is the first imaging test performed in patients with jaundice. It is highly sensitive for identifying bile duct dilation and the level of obstruction. However, if suspicion of bile duct cancer is strong, proceeding directly to cross-sectional imaging is appropriate. Abdominal ultrasound cannot image the distal parts of the bile ducts. Distal bile duct obstruction is often diagnosed by examining biliary dilation. An important aid to ultrasound diagnosis is assessing vascular involvement with duplex ultrasound (colour Doppler), for example, encasement, thrombosis or compression of the portal vein, and encasement or obstruction of the hepatic artery. Endoscopic or Laparoscopic Ultrasound In distal bile duct lesions, endoscopic ultrasound can image tumour spread and regional lymph node status. A thin, illuminated tube with a camera at its tip is passed through the mouth into the stomach and then into the intestines beside the bile ducts, or the procedure is performed with endoscopic ultrasound (EUS)-guided fine-needle biopsy. Tumour size and spread and lymph node enlargement are assessed to plan the next stage, surgery. This procedure is more sensitive for identifying malignant distal tumours than ERCP (endoscopic retrograde cholangiopancreatography) with brushing. It also reduces the risk of infecting the bile ducts. Endoscopic ultrasound does not provide effective or sufficient results for imaging and staging proximal bile duct lesions. Intraductal Ultrasound Intraductal ultrasound (IDUS) may help distinguish malignant from benign narrowing based on bile duct anatomy and characteristic sonographic imaging features. IDUS also helps obtain clear information for bile duct cancer staging. It identifies early lesions and tumour dimensions and yields results approaching %100 in diagnosing extension to nearby organs and blood vessels. In particular, IDUS can clearly identify tumour spread to the pancreas and major hepatic vessels. Multiphasic Contrast-Enhanced Multidetector-Row Computed Tomography (MDCT) Because of its wide applicability, CT imaging is used as an alternative to transabdominal imaging in suspected bile duct cancer. It identifies intrahepatic tumours, the level of bile duct obstruction and liver atrophy. Multiphasic contrast-enhanced multidetector-row computed tomography (MDCT) may also help distinguish benign intrahepatic bile duct narrowing from malignant narrowing (particularly in the portal venous phase) and image nodal regions. Magnetic Resonance Cholangiopancreatography [MRCP] and Magnetic Resonance Imaging (MR) MR combined with MRCP is a noninvasive technique used to assess the intrahepatic and extrahepatic bile ducts and pancreatic duct to identify bile duct cancers before surgery. Unlike endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography [MRCP] does not use contrast within the ducts. However, MRCP does not permit interventions such as gallstone removal, stent placement or biopsy. Cholangiography Cholangiography images the bile ducts through injection of radiographic contrast. It may also be performed using endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography (PTC). Preoperative cholangiography may be used for diagnosis or treatment in patients with bile duct obstruction. However, it is rarely used because equally functional MRCP and MDCT imaging have replaced it.