HEALTH - GALLBLADDER CANCER AND BILE DUCT CANCER SYMPTOMS
What is Gallbladder Cancer?
Gallbladder cancer occurs when normal cells in the gallbladder begin to change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Primary gallbladder cancer is cancer that starts in the gallbladder, as opposed to cancer that began somewhere else in the body and spread to the gallbladder.
The gallbladder is a pear-shaped organ located just under the liver. The gallbladder stores bile, a fluid made by the liver that helps to digest fats. Bile is released from the gallbladder through a tube, called the common bile duct, as food is broken down in the stomach and intestines.
The gallbladder’s wall is made up of three main layers of tissue: the mucosa, which is the innermost layer and covers the wall of the gallbladder; the muscularis, the middle layer of smooth muscle; and the serosa, the outer layer. Primary gallbladder cancer begins in the inner layer and spreads into the outer layers as it grows.
Gallbladder cancer seldom produces symptoms in the early stages. In fact, early gallbladder cancer is often only discovered when the gallbladder is removed as a treatment for gallstones. Otherwise, gallbladder cancer is often quite advanced by the time it's diagnosed.
When gallbladder cancer is caught early, removing your gallbladder or part of the bile duct may eliminate all the cancerous cells. In advanced cases, treatment won't cure gallbladder cancer but can help relieve symptoms and improve your quality of life.
Health: Causes of Gallbladder Cancer/Bile Duct Cancer
Your gallbladder is a small, pear-shaped organ on the right side of your abdomen, just beneath your liver. Its main function is to store bile, a bitter, yellow-green fluid that's produced in the liver cells. Bile is essential for the proper digestion of fats and is one of the main ways your body eliminates drugs, cholesterol and waste products of metabolism. It flows from your liver through a thin tube called the common hepatic duct and enters your gallbladder through another small tube (cystic duct).
When you eat, your gallbladder releases a highly concentrated form of bile into the common bile duct, a continuation of the hepatic and cystic ducts. The bile flows through this duct to the upper part of your small intestine (duodenum), where it begins to break down the fat in your food.
How gallbladder cancer begins
Healthy cells grow and divide in an orderly way — a process that's
controlled by DNA, the genetic material that contains the instructions
for every chemical process in your body. When DNA is damaged, changes
occur in these instructions. One result is that cells may begin to grow
out of control and eventually form a malignant tumor — a mass of
cancerous cells.
Although the exact cause of gallbladder and bile duct cancers isn't clear, researchers believe that DNA in the cells of your biliary tract may be damaged by toxins that are routinely metabolized by your liver. These toxins are released into bile so that they can be eliminated from your body. But if bile empties more slowly than normal, it increases the amount of time your cells are exposed to cancer-causing substances (carcinogens).
Most gallbladder tumors develop in the cells that line the inner surface of the gallbladder. These tumors are most commonly adenocarcinomas — a term that describes the way the cancer cells look when viewed under a microscope.
Gallbladder adenocarcinoma is highly invasive and can quickly penetrate deep into the gallbladder wall, moving through layers of tissue from the inner surface to the outside of the gallbladder. Eventually the cancer may spread to nearby lymph nodes, obstruct the bile duct or invade other organs such as the liver. Cancer cells may also travel through the bloodstream to more remote parts of the body.
Bile duct cancer (cholangiocarcinoma)
Cancer can develop in any part of the bile duct that stretches from
your liver to your small intestine. Many tumors occur in the hepatic
duct just as it leaves the liver (perihilar tumors). Other tumors may
develop in the bile duct near your small intestine (distal tumors) or
inside the liver itself (intrahepatic tumors).
The majority of bile duct cancers are adenocarcinomas that originate in the mucous glands lining the inside of the ducts. By the time these cancers are diagnosed, they often have spread to other tissues and organs.
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Health: Risk Factors of Gallbladder Cancer/Bile Duct Cancer
The following factors can increase a person's risk of both gallbladder and bile duct cancer:
- Gallstones. These solid deposits of cholesterol or calcium salts form in your gallbladder, they are the most common risk factor for gallbladder cancer. The stones may cause your gallbladder to release bile more slowly, which increases the amount of time cells are exposed to toxins. Although most people with gallbladder cancer also have gallstones, the vast majority of people with gallstones never develop gallbladder cancer. Gallstones are the most common digestive disease in the United States, and between 75% and 90% of people with gallbladder cancer have a history of gallstones.
- Age. The chances of developing gallbladder cancer increase as you get older. Most people diagnosed with gallbladder cancer are older than 70. Bile duct cancer is most common in those over 65.
- Gender. Women are about twice as likely to develop gallbladder cancer as men. They're also more likely to have gallstones because the female hormone estrogen causes more cholesterol, the main component of most gallstones, to be excreted in bile. But, bile duct cancers are more likely to occur in men than they are in women.
- Bile duct abnormalities. The pancreatobiliary duct junction is the point where the common bile duct — which carries bile from your liver and gallbladder to your small intestine — joins the pancreatic duct carrying digestive juices from your pancreas. In some people, these two ducts connect in a way that allows pancreatic juices to back up into the bile duct and prevents bile from being quickly emptied into the small intestine. This may irritate the cells lining the gallbladder and bile ducts, increasing the risk of cancer.
- Gallbladder polyps. This type of polyp is a growth that sometimes forms when small gallstones get embedded in the gallbladder wall. Gallbladder polyps bulge inward from the inner gallbladder wall. Some polyps may also be caused by inflammation. Doctors often recommend gallbladder removal for people who have polyps larger than one centimeter because these are more likely to be cancerous.
- Diet. Eating food high in carbohydrates and low in fiber may increase your risk of gallbladder cancer.
- Hazardous chemicals and toxic substances. People exposed to certain industrial chemicals, especially azotoluene, have an increased risk of developing gallbladder cancer. Thorium dioxide (Thorotrast), a dye once used in X-rays, can cause both liver and bile duct cancers. Although Thorotrast hasn't been used for decades, exposure to other toxic materials — including dioxin, nitrosamines and polychlorinated biphenyls (PCBs) — may increase your risk of bile duct cancer.
- Obesity. If you are very overweight (about 30 pounds more than your ideal weight), you're at increased risk of gallbladder cancer. It's estimated that as many as one in every four cases of gallbladder cancer is linked to excess weight.
- Ethnicity. Mexican Americans and Native Americans, particularly in the southwestern United States, are more likely to develop gallbladder cancer than the general population.
- Primary sclerosing cholangitis (PSC). This autoimmune disorder causes your immune system to attack your bile ducts. PSC creates scar tissue that narrows the bile ducts and prevents bile from reaching your intestines. Over time, repeated injury to bile duct tissue can increase the likelihood of developing cancer.
- Ulcerative colitis. Another autoimmune disease, ulcerative colitis is characterized by severe bouts of bloody diarrhea with abdominal pain and cramping.
- Congenital abnormalities of the bile ducts. These include choledochal cysts, which is a dilation or stretching of the common bile duct, and Caroli's disease — a dilation of the bile ducts within your liver (intrahepatic ducts). Over time bile that collects in these dilated spaces may seriously damage the duct lining.
- Bile duct stones. Gallstones sometimes escape the gallbladder and enter the cystic duct, the common bile duct or, occasionally, the duct leading to your pancreas. These migrating stones can cause serious complications, including an increased chance of developing bile duct cancer.
- Parasitic infections. These are primarily a concern in Asian countries. Parasitic infections generally occur when humans eat fish containing the cysts of certain flatworms. The worms migrate to the bile ducts, where they damage the duct lining.
- Family history. A family history of gallbladder cancer slightly increases a person’s risk of developing gallbladder cancer.
- Smoking. Tobacco use may increase the risk of gallbladder cancer.
Health: Symptoms of Gallbladder Cancer/Bile Duct Cancer
People with gallbladder cancer may
experience the following symptoms. Sometimes, people with gallbladder
cancer do not show any of these symptoms. Or, these symptoms may be
caused by a medical condition that is not cancer. If you are concerned
about a symptom on this list, please talk with your doctor or health care provider. Gallbladder cancer is usually not found at an early stage because
the gallbladder is located deep inside the body. Therefore, gallbladder
cancer can be difficult to detect during routine physical examinations.
Sometimes, gallbladder cancers are found unexpectedly after removal of
the gallbladder for other reasons, such as gallstones. When symptoms do
occur, they include:
Symptoms of bile duct cancer (cholangiocarcinoma)
- Jaundice. A yellowing of your skin and the whites of your eyes, along with tea- or coffee-colored urine and light-colored stools, are common initial signs of bile duct cancer.
- Enlarged gallbladder. A blocked bile duct can cause bile to accumulate in your gallbladder, making it larger than normal. Although your gallbladder is hidden behind other organs in your abdomen, your doctor can sometimes feel this enlargement during a physical exam or it may be detected on an ultrasound.
- Intense itching (pruritis). When the flow of bile is obstructed by a tumor, bile salts may be deposited in your skin, leading to intense itching.
Health: Diagnosis of Gallbladder Cancer/Bile Duct Cancer Doctors use many tests to diagnose cancer and
determine if it has metastasized (spread). Some tests may also
determine which treatments may be the most effective. In addition to a physical examination, the following tests may be used to diagnose gallbladder cancer: Biopsy. A biopsy is the removal of a
small amount of tissue for examination under a microscope. Other tests
can suggest that cancer is present, but only a biopsy can make a
definite diagnosis. The sample removed from the biopsy is analyzed by a
pathologist (a doctor who specializes in interpreting laboratory tests
and evaluating cells, tissues, and organs to diagnose disease). The sample of tissue can be taken one of several ways: during a
surgery; by using a minimally invasive surgical technique known as
laparoscopy; or by fine needle or thick needle aspiration (a core
biopsy), using a computed tomography (CT or CAT) scan or ultrasound to
guide the needle placement. In some cases, bile duct cells and tiny fragments of duct tissue can be obtained
through a procedure known as biliary brushing. As in ERCP, an endoscope
is inserted into the bile duct where it empties into your small
intestine. But instead of injecting dye and taking X-rays, your surgeon
uses a small brush placed in the endoscope to scrape cells and bits of
tissue from the lining of your bile duct. Bile duct cells and tiny fragments of duct tissue can be obtained
through a procedure known as biliary brushing. As in ERCP, an endoscope
is inserted into the bile duct where it empties into your small
intestine. But instead of injecting dye and taking X-rays, your surgeon
uses a small brush placed in the endoscope to scrape cells and bits of
tissue from the lining of your bile duct. Endoscopic retrograde cholangiopancreatography (ERCP). This
test allows the doctor to see inside the body. The person is lightly
sedated, and the doctor inserts an endoscope through the mouth, down
the esophagus, and into the stomach and small bowel. A smaller tube or
catheter is passed through the endoscope and into the bile ducts. Dye
is injected into the ducts, and the doctor takes x-rays that can show
whether a tumor is present in the area around the bile ducts.
Sometimes, the procedure can be helpful to detect a tumor starting in
the gallbladder. A plastic or metal stent can be placed across an
obstructed bile duct during ERCP to help relieve jaundice if it is
present. An experienced gastroenterologist (a doctor who specializes in
the function and disorders of the gastrointestinal tract) should
perform this procedure. This procedure is used more commonly to find
cancer of the bile duct than to find gallbladder cancer, but it may
also be used if the gallbladder cancer spreads and blocks the bile
ducts. Percutaneous cholangiography. In this procedure, a thin
needle is inserted through the skin and into the gallbladder area. A
dye is injected through the needle so that a high-contrast image will
show up on x-rays. By looking at the x-rays, the doctor may be able to
see whether there is a tumor in the gallbladder. More commonly, a
cholangiography provides images of the bile ducts and may not show a
tumor in the gallbladder. However, it is excellent in detecting the
site of a blocked bile duct. Laparoscopy. Laparoscopy uses an endoscope to look at the
gallbladder and other internal organs. The tube is inserted through a
small incision in the abdomen. Blood tests. The doctor may take samples of blood to check
for abnormal levels of bilirubin and other substances. Bilirubin is a
chemical that may reach high levels in people with gallbladder cancer
due to blockage of the common bile duct by a tumor. CT scan. A CT scan creates a three-dimensional picture of the
inside of the body with an x-ray machine. A computer then combines
these images into a detailed, cross-sectional view that shows any
abnormalities or tumors. Sometimes, a contrast medium (a special dye)
is injected into a patient’s vein to provide better detail. Magnetic resonance imaging (MRI). An MRI uses magnetic
fields, not x-rays, to produce detailed images of the body and can be
used to find out whether the cancer has spread outside the gallbladder.
A contrast medium may be injected into a patient’s vein to create a
clearer picture. Ultrasound. An ultrasound uses sound waves to create a
picture of the internal organs. Tumors generate different echoes of the
sound waves than normal tissue, so when the waves are bounced back to a
computer, creating images, the doctor can locate a mass inside the body. Endoscopic ultrasound (EUS) is a technique that can sometimes provide
even better images. In this test, an ultrasound transducer is attached
to the end of a flexible, lighted viewing tube (endoscope). The
endoscope is passed down your throat into your stomach and duodenum,
and from there into the common bile duct. X-ray. An x-ray is a picture of the inside of the body. For
instance, a chest x-ray can help doctors determine if the cancer has
spread to the lungs. The patient may be asked to swallow barium, which
coats the digestive tract, to enhance the image on the x-ray (called a
barium swallow). Positron emission tomography (PET) scan. A PET scan is a way
to create pictures of organs and tissues inside the body. A small
amount of a radioactive substance is injected into a patient’s body and
absorbed by the organs or tissues being studied. This substance gives
off energy that is detected by a scanner, which produces the images.
Health: Staging of Gallbladder Cancer/Bile Duct Cancer
The following stages are used for gallbladder cancer:
Stage 0 (Carcinoma in Situ)
In stage 0, abnormal cells are found in the innermost (mucosal) layer of the gallbladder. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.
Stage I
In stage I, cancer has formed. Stage I is divided into stage IA and stage IB.
- Stage IA: Cancer has spread beyond the innermost (mucosal) layer to the connective tissue or to the muscle (muscularis) layer.
- Stage IB: Cancer has spread beyond the muscle layer to the connective tissue around the muscle.
Stage II
Stage II is divided into stage IIA and stage IIB.
- Stage IIA: Cancer has spread beyond the visceral peritoneum (tissue that covers the gallbladder) and/or to the liver and/or one nearby organ (such as the stomach, small intestine, colon, pancreas, or bile ducts outside the liver).
- Stage IIB: Cancer has spread:
- beyond the innermost layer to the connective tissue and to nearby lymph nodes; or
- to the muscle layer and nearby lymph nodes; or
- beyond the muscle layer to the connective tissue around the muscle and to nearby lymph nodes; or
- through the visceral peritoneum (tissue that covers the gallbladder) and/or to the liver and/or to one nearby organ (such as the stomach, small intestine, colon, pancreas, or bile ducts outside the liver), and to nearby lymph nodes.
Stage III
In stage III, cancer has spread to a main blood vessel in the liver or to nearby organs and may have spread to nearby lymph nodes.
Stage IV
In stage IV, cancer has spread to nearby lymph nodes and/or to organs far away from the gallbladder.
For gallbladder cancer, stages are also grouped according to how the cancer may be treated. There are two treatment groups:
Localized (Stage I)
Cancer is found in the wall of the gallbladder and can be completely removed by surgery.
Unresectable (Stage II, Stage III, and Stage IV)
Cancer has spread through the wall of the gallbladder to surrounding tissues
or organs or throughout the abdominal cavity. Except in patients whose cancer
has spread only to lymph nodes, the cancer is unresectable (cannot be completely
removed by surgery).
Staging biliary tract cancers
Staging tests help determine the size and location of cancer and
whether it has spread. This information helps determine the best
treatment options.
Doctors stage biliary tract cancers in several ways. One method is as follows:
- Resectable. These cancers have not spread beyond the walls of the gallbladder or bile ducts and can be entirely removed in an operation. The term "resectable" refers to a cancer that can be removed.
- Unresectable. At this stage, the cancer has spread to nearby lymph nodes or other organs such as the liver, pancreas, stomach or intestines and can't be completely removed.
- Recurrent gallbladder cancer. Recurrent gallbladder cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the gallbladder or in other parts of the body.
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Health: Conventional Treatment for Gallbladder Cancer/Bile Duct Cancer
The treatment of gallbladder cancer depends on the size and location of the tumor, whether the cancer has spread, and the patient’s overall health. Gallbladder cancer may be treated with one or more techniques including surgery, chemotherapy, or radiation therapy. If detected at an early stage, gallbladder cancer has a much higher chance of being successfully treated.
Descriptions of the most common treatment options for gallbladder cancer are listed below:
Surgery
A surgical oncologist is a doctor who specializes in treating cancer using surgery. The following are types of surgery used in the treatment of gallbladder cancer:
Cholecystectomy. Also called a simple cholecystectomy, this procedure involves the removal of the gallbladder. An extended cholecystectomy is the removal of the gallbladder, one inch or more of liver tissue located next to the gallbladder, and all of the lymph nodes in the region.
Radical gallbladder resection. This procedure involves the removal of the gallbladder, a wedge-shaped section of the liver near the gallbladder, the common bile duct, part or all of the ligaments between the liver and intestines, and the lymph nodes around the pancreas and nearby blood vessels.
Palliative surgery. Surgery may sometimes help relieve symptoms caused by gallbladder cancer, even if the tumor cannot be removed. For example, surgery may relieve a blockage of the bile ducts or intestines.
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment for gallbladder cancer is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. Radiation therapy may be used before surgery to shrink the size of the tumor or after surgery to destroy any remaining cancer cells. In some cases, radiation therapy is given during surgery to directly target the area of the tumor and protect healthy organs from the effects of traditional radiation therapy. This procedure is called intra-operative radiation therapy, or IORT.
Side effects of radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and damage to nearby structures such as the liver or intestines. Most side effects go away soon after treatment is finished.
Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. Some people may receive chemotherapy in their doctor’s office; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time.
Chemotherapy may be given before surgery to shrink the tumor or after surgery to destroy any remaining cancer cells. It also may be combined with radiation therapy. Chemotherapy can be given by mouth or injection. The drugs that are commonly recommended include gemcitabine (Gemzar) and fluorouracil (5-FU, Efudex). The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.
Bile duct cancer
Surgery usually offers the best chance for people with bile duct
cancer. But the type of operation you may have will vary, depending on
the location of the cancer and how extensive it is:
- Perihilar tumors. Tumors that develop where the hepatic duct leaves your liver (perihilar tumors) are usually treated by surgically removing a portion of the bile duct, the gallbladder and surrounding lymph nodes.
- Distal tumors. Treatment for these tumors, located in the bile duct near your small intestine, is often by what's known as a Whipple resection. In this operation, your surgeon removes part of your pancreas, the common bile duct and your gallbladder, as well as a small portion of your intestine where the common bile duct and pancreatic duct enter the intestine together.
- Tumors that can't be removed. When a tumor is too close to major blood vessels, your surgeon may suggest an operation to bypass some of your small intestine. This may help prevent further blockage of your bile duct and digestive tract and may also help relieve symptoms, but won't cure the cancer. If a bypass isn't an option, your surgeon may place metal or plastic tubes known as stents into the bile duct to keep it open. After surgery, your doctor may also recommend radiation or chemotherapy.
Health: Complications of Gallbladder Cancer/Bile Duct Cancer
Gallbladder and bile duct tumors can cause a number of complications including:
- Nausea and vomiting. These symptoms, along with jaundice, can result when a tumor blocks the common bile duct.
- Malabsorption. A growing tumor in the common bile duct can press against the upper part of the small intestine, preventing food and digestive enzymes from passing normally into the duodenum. This can lead to malabsorption and malnutrition.
- Metastasis. This is the most serious health complication of biliary tract cancer. Your gallbladder and bile ducts are surrounded by a number of vital organs, including your liver, stomach, pancreas and intestines. Because biliary tract cancers are rarely discovered in the early stages, they often have time to spread to these organs or to nearby lymph nodes.
Health: Prevention of Gallbladder Cancer/Bile Duct Cancer
Although it's usually not possible to prevent gallbladder and bile duct cancers, you can take steps to reduce your health risk. In general, eating a healthy diet and exercising regularly can lower your health risk of many types of cancer.
Aim for at least five servings of fruits and vegetables every day, along with foods from other plant sources such as whole-grain breads, cereals, rice and beans. In addition, try to limit your intake of high-fat foods.
Other steps you can take to reduce your risk of many types of cancer include the following:
- Maintain a healthy weight. This is one of the best ways to reduce your chance of developing gallbladder cancer. If you need to lose weight, remember that a slow, steady loss is the healthiest way to reach your goals. Regular exercise can help you maintain a healthy weight.
- Stop smoking. You can also greatly reduce your risk of many types of cancer by stopping smoking. Cigarette smoke contains carcinogens that can damage the DNA that regulates cell growth. Tobacco use is associated with 180,000 cancer deaths annually. Talk to your doctor about the best ways to quit, or contact the American Cancer Society at 800-ACS-2345, or 800-227-2345, or the National Cancer Institute's quit line at 877-44U-QUIT, or 877-448-7848, for more health information.
Protecting yourself against bile duct cancer
Avoid toxic chemicals. Among these are highly hazardous substances such
as dioxin — a byproduct of plastics and chlorinated pesticide
manufacturing — and PCBs, which were used in a number of industrial
materials in the past. Because PCBs don't break down easily, they're
still found worldwide in the air, water, soil and especially in fish.
Also implicated in bile duct cancers are nitrosamines, a group of
carcinogenic chemicals found in products ranging from tobacco leaves to
cured meats.
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Disclaimer: This information is not presented by a medical practitioner. Therefore any content of this site is strictly intended for educational and informational purpose only. Any access to this site is strictly on a voluntary basis and at the sole discretion of the user. No content of this site is intended as a substitute for medical advice, diagnosis or treatment, nor constitute the practice of any medical profession or health care provider. The information provided on this site is here to educate visitors on health issues that may affect their lives. Otherwise, always seek the advice of your physician or other qualified health care provider with any questions you may have regarding a medical condition. And never disregard professional medical advice or delay in seeking it because of something you have read.
Sources: NIH News In Health/National Institutes of Health/National Library of Medicine/Dept of Health and Human Services_______________________________________________________________________________________________________
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