Cancer of the Bile Duct – Diagnosis, treatment, management and Prevention.

Whenever “cancer” is mentioned, many people equate it with death. In the case of cancer of the bile duct this perception is invariably true because there are very few treatment options. Surgical excision and liver transplant costs are very high and do not assure the necessary success.

A Cancer is a malignant growth which is characterized by the proliferation of cancerous (malignant cells) which tend to invade surrounding tissues and metastasize to form new growths in distant areas.

Figure 1. Normal Exterior view of Abdomen.

Known Causes: More that 200 causes of cancer are now known. However, the following are of immediate concern. These include, but are not limited to, the following:

Carcinogens: Cigarette smoke, excessive amounts of sunlight.

Our age: Older people more likely to get cancer.

Our genetic make up: BRCA1 and BRCA2 gene carriers more likely to get breast cancers.

Our immune system: People with defective immune systems are more likely to get cancer of the bile duct. Patients suffering from AIDs and other immunodeficiency disorders fall in this category.

Our Diets: Fruit, veg, Fibre, Vitamins A, C, E and D, fish oils lower cancer risks.

Increased risk factors for cancer: consumption of large amounts of animal fats, red meats & processed meats. High consumption of alcohol.

Our immediate environment: Tobacco, Sun, x-rays, asbestos

Some viruses are known to cause cancers of the bile duct: These include the HPV, T-cell Leukaemia virus

Persons who are high risk for getting cancer of the bile duct.

People who have chronic inflammation of the bile duct, called sclerosing cholangitis are in the high risk category for this type of cancer. (Cholangitis is the medical term for bile duct inflammation).

Patients who suffer from Ulcerative colitis may develop sclerosing cholangitis which may lead to cancer of the bile duct.

Patients who have stones in the bile duct are in the high risk category. Gall stones cause chronic inflammation which leads to cancer of bile duct.

Diseases of the liver and bile duct increase the risk of developing bile duct cancer. It is for this reason that the following diseases increase the probability of getting cancer of the bile duct. Polycystic liver diseases, choledochal cysts, congenital dilation of the intrahepatic bile ducts (Caroli syndrome), cirrhosis (scar tissue formation in the liver) and Cirrhosis due to long-standing sclerosing cholangitis.

Cirrhosis of the liver caused by long-standing viral hepatitis has a greater impact on a person’s risk of developing hepatocellular cancer.

Infection by liver flukes, food- or water-borne parasites invade the bile duct, cause of bile duct cancer. Commonest: Clonorchis sinensis & Opisthorchis viverrini. These flukes are common in Asia.

Aging: Older people are more likely to get bile duct cancer. Over 70% of patients with bile duct cancer are older than age 65. Other forms of cancer are also more common in the elderly.

Other factors: Thorotrast (thorium dioxide), Radioactive chemicals, Dioxin, nitrosamines, and polychlorinated biphenyls (PCBs).

Smoking increases the bile duct cancer rate.

Viral Hepatitis: Infection with either hepatitis B or hepatitis C.

Classification of Cancers. There are many ways to classify cancers/tumours. In this article three methods are discussed. The first method of classification is according to the site of Origin of the cancer.

Adenocarcinomas – These are cancers which originate from glandular tissue.

Blastomas – These are tumours which originate from embryonic tissue of organs of the body.

Carcinomas – These originate from epithelial tissue (i.e., tissue that lines organs and tubes)

Leukemias – These originate from tissues that form blood cells.

Lymphomas – These originate from lymphatic tissue of the lymphatic system.

Myelomas – These cancerous cells originate from bone marrow, usually long bones.

Sarcomas – Originates in connective or supportive tissue (e.g., bone, cartilage, muscle)

Classification of Cancers: According to grade – This grade usually refers to degree of pathological abnormality in cell structure and function. The following distinctions (grades) are usually identified (degree of cell abnormality).

Malignant cells or cells which need to be examined are obtained by biopsy. A biopsy is a special procedure during which a specially trained doctor obtains a small cutting (sample) of the suspicious cells. These cells are then examined under a microscope. The degree pf abnormality of the cells determines the grade of the cancer. Increasing abnormality increases the grade.

• Grade 1 cancer is present when cells are slightly abnormal and are well differentiated (Least cancerous, least abnormality). The probability of an effective cure is high when the patient has only grade 1 cancer.
• Grade 2 cancer is present when cells are abnormal and are moderately differentiated. The probability of effective cure decreases as the grade increases.
• Grade 3 cancer is present when cells are abnormal and poorly differentiated. The prognosis of cure decreases with increasing grades.
• Grade 4 cancer is present when cells are immature and undifferentiated. (Highly cancerous, most abnormal). The probability of an effective cure is low because the cells are immature, highly undifferentiated and usually divide rapidly.

The third classification of cancers is according to the stage of progression of the cancers. This is often referred to as staging.

Figure 2. External view of patient with cancer of the bile duct.

Staging is the classification of the extent of the disease. There are several types of staging methods referenced in medical literature. The TNM system classifies tumours (cancers) by tumour size (T), the degree of regional spread or node involvement (N), and distant metastasis (M).

Tumor (T): Tumour is present.

T0 : No evidence of tumour.

Tis: Carcinoma (tumour) in situ (limited to surface cells)

T1-4 Increasing tumour size and involvement. The numbers one to four refer to the size of the tumour. One being a small tumour, four being the largest.

Node (N)

N0: No lymph node involvementN1-4Increasing degrees of lymph node involvementNxLymph node involvement cannot be assessed

Metastases (M) This refers to metastasis.

M0: No evidence of distant metastases. This does not necessarily mean that there is no metastasis. It means that there is no evidence of metastasis. Small metastatic cells may go undetected.

M: 1Evidence of distant metastases. The evidence may be based on history or radiological.

Cancer of the Bile Duct – Affected Parts of the Human Body.

According to simple anatomical studies the bile duct is a small tube which connects the gall bladder to the duodenum. The main function of the bile duct is to transport bile. However, even simple obstructions to this duct can have very damaging consequences.

Cancer of the bile duct obstructs and flow of bile from the storage area to the duodenum where it is needed for the digestive process. The obstruction causes the bile to build up in the gall bladder and enter the blood system.

When bile (bilirubin) enters the blood system it is carried to all parts of the body including the heart. The patient becomes yellow. This symptom is known as jaundice.

The jaundice will cause the patient to complain of an itchy feeling. This is called icterus. will a yellow skin, slow heart rate, jaundice and pale stool.

Metastasis will eventually obstruct vital organs and or cause the patient to bleed to death.

Diagnosis of Cancer of the Bile duct. Prior to commencement of treatment, proper diagnosis is important. Sometimes, the patient will feel that there is unnecessary wastage of time. However, the benefits of accurate diagnosis cannot be overstated.

History and Presentation – Doctor / Nurse takes history. Signs, Symptoms & Presentation. Physical examination.

Typical Signs and symptoms (yellow skin, itching, bradycardia = heart rate of less than 60 beats per minute)

Blood chemistry: Alkaline phosphatase (Indicates damaged bile duct cells. Differential diagnosis of cancer cannot be confirmed with this test.

Tumor Markers: Cancer bile duct, will result in elevation of 2 markers — carcinoembryonic antigen (CEA) and CA 19-9.

Imaging Tests: Ultrasonography (ultrasound): Ultrasound uses sound waves to produce images of internal organs.

Patterns of echoes distinguish some types of benign and malignant tumors. Newer techniques, known as endoscopic or laparoscopic ultrasound,

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around the patient.

A fine-needle biopsy sample (tiny fragment of tissue) or a core-needle biopsy.

Figure 3. Diagramatic Location of Bile Duct and associated organs.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays

A new method called MRI cholangiopancreatography. This technique can often outline the exact site of bile duct blockage.

Endoscopic retrograde cholangiopancreatography (ERCP): In this procedure, a doctor passes a long, flexible tube down the patient’s throat, through the esophageus and stomach, and into the common bile duct.

Cholangiography: Contrast dye is injected into the bile duct and x-ray pictures are taken. A radiologist injects dye through a needle that has been placed in a dilated (opened) bile duct.

Angiography: Cannula is inserted into the blood vessel to be studied. Contrast dye is injected rapidly and a series of x-rays taken.

Laparoscopy: The doctor views the internal organs using an instrument called a laparoscope. The instrument is inserted into the patient through a cut in the abdominal wall.

Biopsy: A small amount of tissue from bile duct is removed and examined under a microscope to be sure of that diagnosis. This is called HISTOLOGY.

HISTOLOGY. Final confirmation of Cancer of Bile Duct.

Treatment of cancer of the Bile duct. As stated earlier, there are very few treatment options to deal with cancer of the bile duct. There are many reasons for this but the most compelling one is that the bile duct is a soft gland buried deep inside another which is equally soft. The highly vascular nature makes it easy for the disease to spread. Most often diagnosis is delayed because, in the early stages, many of the symptoms may be dismissed or mistaken for abdominal discomfort.

Surgical removal (resection) is currently on of the only optimistic hope for a cure for cancer of the bile duct. This operation is very difficult however the most experienced surgeons are able to obtain good outcomes for the patient.

The treatment of choice for bile duct cancers within the liver (Intrahepatic cholangiocarcinomas) is segmental resection. This procedure involves the resection of a portion of the liver.

In some instances Complete removal of the liver (hepatectomy) may be necessary due to th presence of metastasis deposits. In these situations, liver transplantation may also be attempted if the patient is young.

Prevention of cancer of the Bile duct.

Prevention focuses on eliminating the known causes of this deadly disease.

Thorotrast has been banned in many countries because it is a known cause of cancer of the bile duct. Thorotrast is a radio-opaque dye which was used for the diagnosis of bile duct cancer.

Avoidance of exposure to the hazardous chemicals can reduce bile duct cancers.

Prevent Cirrhosis because it increases the risk of developing hepatocellular cancer and, to a lesser degree, bile duct cancer.

Vaccination against the hepatitis B virus and taking precautions to avoid blood-borne hepatitis. Also, vaccination against sexually transmitted infections by other viruses, and avoiding alcohol abuse may lower the numbers patients with cancers of the bile duct.

Eliminate liver flukes to reduce this cancer. Liver flukes are the major causes of liver diseases in Asia.

Impacts of bile duct Cancer on Society.

Pain: Person who has Cancer of bile duct suffer from pain when eating, drinking and also when not doing anything.

Quality of life is affected as activities of daily living become impossible.

Quantity of life is decreased by early death.

Economic Loss due to early death.

Loss of a loved one causes pain and suffering to surviving members of family.

Economic costs: Billions of dollars in lost productivity and spent on treatments.

Prevention and management: Cancer of the bile duct is rare but the economic losses and associated pain and sufferings of the patient, society and loved ones cannot be over estimated. Policy makers and governments need to play a greater role in the prevention and management of this deadly, most often fatal disease.

Education of Public: The public needs to be made aware of the strategies which focus on prevention. Reduction in the alcohol consumption will go a long way to prevent this cancer.

Public Vaccination Programmes. These attack the problem before it begins and is a relatively cheap option. The author is concerned about the recent decrease in the numbers of children being vaccinated.

Education of Professionals: (Nurses, Doctors, pharmacists, pathologists, chemists, scientists, parasitologists, administrators, civil engineers). These professions play strategic roles in the prevention of this disease.

Legislation – Local, state, national and international legislation. Substances which are known to cause cancer of the bile duct or any other cancer should be prohibited by legislation. When complete prohibition is not possible limited usage may be a suitable alternative.

Personal awareness: Education of the individual consumer and users should also focus on the reduction in the consumption of fatty foods, red meats and low fibre foods.

Increased consumption of fruit & vegetables. This is an adjunct to a healthy life and will also aid in the prevention of obesity. It is now known that childhood obesity is a major problem in the western world. This has contributed to the rise in childhood diabetes and childhood hypertension.

Disclaimer. This article is written for Nursing students and is not to be used for diagnostic, treatment and/or management of cancer of the bile duct. Please consult a qualified physician if you suspect that you have bile duct cancer.