What is bile duct cancer (cholangiocarcinoma)?
Small tributaries join together to form right and left hepatic duct from right and left side of liver. Right and left duct join just outside the liver to form common hepatic duct. Gallbladder duct joins the common hepatic duct to form common bile duct(CBD). CBD drains the liver juice /bile into duodenum, just before entering the duodenum CBD is joined for short distance by pancreatic duct.Bile duct cancer can arise in any of its part. Mainly divided into intahepatic and extrahepatic.
- Obstructive Jaundice
- Abdominal pain
- Weight loss
- LFT- to ascertain jaundice and level of jaundice
- Tumour marker CA19-9, CEA raised level of tumour marker is suggestive of tumour though not confirmatory.
- Ultra sound abdomen is the intial scan which gives an idea about the tumour site.
- Triphasic CT scan Abomen- Show the site of the tumour, its local spread, involvement of the vasculature.
- MRI is another useful scan that yields information similar to CT, but also gives three-dimensional reconstruction of the bile ducts (called MRCP). This can provide a roadmap for the biliary anatomy above and below the tumour.
- PET scanning can detect cholangiocarcinoma as well as the presence of distant spread, but its use is not routine.
- EUS (endoscopic ultrasound) increasingly plays a role in the diagnosis of cholangiocarcinoma and can also guide fine needle aspiration of a cell sample.
The treatment options for cholangiocarcinoma are determined by stage of the disease in terms of tumour size and extent, involvement of the major blood vessels flowing into the liver, and the presence or absence of metastases.
Only surgical resection if it is possible with clear margin is the cure for cholangiocarcinoma.But most of the patient at presentation are unresectable.
Intrahepatic and hilar cholangiocarcinoma will require major liver resection so if the level of jaundice is high then it has to be brought down by stenting through percutaneous route. If the remanant liver volume is not sufficient then preoperative Portal vein embolisation need to be done to increase the liver volume.
Lower end cholangioca will require pancreaticoduodenectomy.(Whipples operation).
Long term survival rate in most series is upto 40% (5 year survival rate). Operative mortality is upto 5-10% and morbitity upto 40% is to be expected after major resection.
Biliary Stenting plastic or metal may be done for relief of pruritis and cholangitis if present.
Chemotherapy and radiotherapy has not shown to be effective in cholangiocarcinoma in most of the series if surgical resection cannot be done.