GALLBLADDER CANCER
Patient Education Material
How the Gallbladder and Bile Ducts work:
The gall bladder is a small pouch that stores bile. Bile is a green colored fluid produced by the liver cells. It is collected within the bile ducts and is transported to the gall bladder for storage. The bile from liver mix up with the food from stomach and helps to absorb vitamins (like vitamin D and E) and is required for the process of breaking down fats from our diet.
The presence of food within the first part of small intestine (duodenum) stimulate 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.
Cancer:
The human body is made up of millions of cells. These cells have different shapes and functions in different parts of the human body. The routine wear & tear of the body cells is controlled by a process called the cell cycle. This process is 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 that form a lump are malignant (cancerous); others are 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 can be diagnosed 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 the cancer.
Causes of Gallbladder Cancer
Is a rare cancer of the digestive system. We don’t know what causes most gall bladder cancers. But there different factors that may increase your risk of developing it. These include:
Age: Gall bladder cancer is more common in people over the age of 75.
Gallstones and inflammation: People with a history of gallstones or an inflamed gall bladder (cholecystitis) have a higher risk. But most people who have gallstones or an inflamed gall bladder do not develop gall bladder cancer.
Polyps: These are non-cancerous (benign) tumors of the gallbladder. Having polyps increases the risk of developing gall bladder cancer.
Porcelain gall bladder: This is when calcium builds up in the wall of the gall bladder. People with this condition have a slightly increased risk.
Abnormal bile ducts: Gall bladder cancer is slightly more common in people born with abnormal bile ducts.
Smoking: People who smoke cigarettes have a higher risk.
Obesity: Being very overweight can also increase your risk.
Family history: Close relatives of people with gall bladder cancer have a slightly higher risk. A close relative is a parent, brother or sister.
Early gallbladder cancer does not usually cause symptoms. It is often found when someone has surgery to remove gallstones. But most people who have surgery for gallstones will not have gallbladder cancer.
Symptoms of Gallbladder Cancer:
Early gall bladder cancer often does not cause any symptoms. It often discovered when someone surgery to remove gallstones. Later stages of gall bladder cancer may cause symptoms such as pain in the tummy (abdomen) or sickness. Most gall bladder cancers are only found at an advanced stage. They can cause different symptoms, including:
- sickness
- high temperatures (fevers)
- weight loss
- pain in the tummy (abdomen).
If cancer blocks the bile duct, it may stop the flow of bile from the gall bladder into the small bowel. This causes bile to flow back into the blood and body tissues. This can lead to:
- the skin and whites of the eyes becoming yellow (jaundice)
- urine becoming a dark yellow colour
- pale stools (bowel motions)
- itchy skin.
These symptoms caused other problems, such as gallstones, or an infection of the gallbladder. But it is important to get them checked by your doctor.
Gallbladder Cancer diagnosed
Gallbladder cancer diagnosed by chance during an operation to remove the gall bladder. This surgery usually because of gallstones or inflammation.
Or you may be diagnosed after seeing your GP to have your symptoms checked. Your GP will then refer you to a hospital specialist. At the hospital, the specialist doctor will ask you about your general health and any previous medical problems. They will examine you and take blood samples. This is to check your general health and that your liver is working properly. They may also do the following tests:
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 LFT’s (bilirubin level in your blood will be high due to the blockage of the bile duct).
Hemoglobin (Hb level) can be low
Tumor markers. These are substances normally seen in the blood, however, in people with a cancer they may be high. In bile duct cancer, the tumor marker that has been associated with it is Ca19.9.
Ultrasound scan
CT scan
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.
Histology/cytology:
All of the previously mentioned tests may lead the doctor to diagnose bile duct cancer. However, the only definite way to confirm this diagnosis to examine some of the abnormal tissue (cancer cells) under a microscope. If a sample of tissue required we may perform a biopsy. This when a needle is 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 be obtained after the operation, by the laboratory.
Laparoscopy:
This a small operation that allows the doctors to look at your gallbladder, liver, and other organs close to the gall bladder. It is done under a general anesthetic and you will have a short stay in hospital. While you asleep under anesthetic, the doctor makes a small cut (incision) in your tummy (abdomen). They will insert a thin, flexible tube with a light and camera (laparoscope). They may take a small sample of tissue (biopsy) to look at under a microscope. After a laparoscopy, you will have one or two stitches in your tummy.
You uncomfortable wind or shoulder pains for several days after the operation. You can often ease the pain by walking or taking sips of peppermint water.
Staging of gallbladder cancer
The stage of cancer describes its size and whether it spread from where it started. Knowing the stage of cancer helps doctors decide on the best treatment for you. Cancer can spread in the body, either in the bloodstream or through the lymphatic system. The lymphatic system part of the body’s defense against infection and disease. It made up of a network of lymph nodes linked by fine tubes (lymph vessels). Doctors will usually look at the nearby lymph nodes to find the stage of cancer.
four stages of gallbladder cancer:
Stage 1
Cancer affects only the wall of the gall bladder.
Stage 2
Cancer spread through the wall of the gall bladder, but not to nearby lymph nodes or surrounding organs.
Stage 3
Cancer spread to lymph nodes close to the gall bladder or has spread to the liver, stomach, colon or small bowel.
Stage 4
Cancer spread very deeply into two or more organs close to the gall bladder, or it has spread to distant lymph nodes or organs, such as the lungs. This known as metastatic or secondary cancer.
If cancer comes back after it first treated, it known as recurrent cancer.
Treatment of Gallbladder Cancer
The treatment you have depends on a number of factors, including:
- your general health
- the position and size of the cancer
- Whether it has spread to other areas of the body.
Surgery
Surgery may be offered as a potentially curable or palliative treatment. At present complete surgical removal of the cancer offers the only possible cure. Sometimes doctors find cancer by chance when they are doing keyhole surgery to remove the gall bladder (laparoscopic cholecystectomy). If this happens, they change the operation to open surgery. They remove the gall bladder and surrounding tissues through a larger cut in the tummy. This makes it easier to remove all cancer.
Cancer may also be found after surgery for gallstones. When doctors examine the gall bladder. If this happens, you may need further surgery to try to make sure all cancer removed. If cancer spread outside the gall bladder, you may have a larger operation called a radical cholecystectomy to remove:
- the gall bladder
- the surrounding tissues
- the lymph nodes and parts of other organs.
More about surgery:
After your operation, you will stay in an intensive care ward for the first couple of days. You will then be moved to a general ward until you recover. Most people need to be in the hospital for about 8-10 days after this operation.
Some people may have problems with bloating, wind, or diarrhea after their gall bladder removed. These problems usually improve within a few weeks.
Chemotherapy
The treatment of cancer with drugs called chemotherapy). This treatment 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 offered to treat any cancer that may remain after surgery. Each dose of chemotherapy (single or combination) 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 is 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.
Side effects of Chemotherapy
The side effects depend on the drug or combination of drugs you are given. Your doctor or nurse will tell you the drugs you are going to have and the likely side effects. Chemotherapy drugs can reduce the number of white cells in your blood during treatment. This will make you more likely to get an infection. It is very important to contact the hospital straight away if you have any signs of infection. Your doctor or nurse will give you advice about what to do if this happens.
Chemotherapy can also cause other side effects, such as:
- feeling tired
- a sore mouth
- feeling sick (nausea) or being sick (vomiting)
- diarrhoea
- hair loss.
Let your doctor or nurse know about any side effects during treatment. They can give you advice and help to reduce these.
Radiotherapy
Radiotherapy uses high-energy x-rays to destroy the cancer cells, while doing as little harm as possible to normal cells. It may be used to relieve symptoms if gallbladder cancer has spread. You may only need a few treatments and the side effects are usually mild. We can send you more information about radiotherapy.
Blockages and stents
If the cancer is blocking your bile duct, this can often be treated with a flexible plastic or metal tube called a stent. The stent holds the duct open, so it is no longer blocked.
Bile duct stents are usually put in using an ERCP. The doctor can see the narrowing caused by the blockage in the bile duct by looking at x-rays. They stretch the narrowing using dilators (small inflatable balloons). They then insert the stent through the endoscope so the bile can drain. If you have any discomfort while this is being done, it is important to let your doctor know. The Endoscopic Retrograde Cholangio-Pancreatogram (ERCP) and it’s done by gastroenterologists/ hepatologists. This is preferred way of stent placement as it is more convenient for the patient.
In details:
In case of failed ERCP; the other way to insert the stent called Percutaneous Transhepatic CholangioPancreatogram (PTC) and this procedure is done by specialist doctors called as interventional radiologists. This involves inserting the stent through the skin (percutaneous) and liver (transhepatic) into the top of the bile duct, using a needle and tube. The doctor injects some local anesthetic into the skin to numb it. They then insert a long, thin, flexible needle through the skin into the liver. The doctor looks at x-ray images on a screen to help them guide the needle to the bile duct and inject a dye. You may feel warm all over when the dye is injected. This is normal and the feeling wears off quickly.
more about
The dye flows through the ducts, showing the area that is blocked. The doctor passes a fine guidewire along the needle into the blockage in the bile duct. A stent then passed along this wire. The stent holds open the bile duct where it has narrowed, allowing fluid to flow through it again. You may feel some pushing when the wire and stent are being put in. If this is uncomfortable or painful, let the doctor know so that you can be given painkillers.
To help prevent infection, you will be given antibiotics before and after the procedure. You will probably need to stay in hospital for a few days.
Sometimes a stent needs to be replaced if it becomes blocked or gets infected. If a plastic stent has been in place for a long time, it may need to be replaced with a new one.
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 be used and inserted into the duodenum to allow you to eat and drink, without nausea and/or vomiting
Palliative care:
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 be offered to you if you are undergoing treatment such as chemotherapy, which not expected to offer you a cure.
Follow-up
After your treatment, you will have regular check-ups and possibly scans or x-rays. These may continue for several years. Let your doctor know as soon as possible if you have any problems or notice new symptoms between these times.