What Is a Cholangiocarcinoma?

Cholangiocarcinoma refers to a malignant tumor originating from the extrahepatic bile ducts including the hilar region to the lower end of the common bile duct. Its etiology may be related to diseases such as bile duct stones and primary sclerosing cholangitis. Clinical methods such as surgery, radiation therapy, and chemotherapy can be used, but the prognosis is poor.

Basic Information

English name: carcinoma of bile duct
Visiting department: Surgery, Oncology
Multiple groups: 50 70 years old male

Common causes: May be related to bile duct stones, primary sclerosing cholangitis, etc.
Common symptoms: Painless progressive exacerbation of jaundice
Contagious: no

Causes of bile duct cancer

The cause of cholangiocarcinoma is unknown. May be related to the following factors:

Bile duct stones

About 1/3 of patients with bile duct cancer have bile duct stones, and 5% to 10% of patients with bile duct stones will develop bile duct cancer, indicating that the bile duct is stimulated by stones for a long time, and epithelial hyperplasia changes may be related to the occurrence of bile duct cancer.

2. Clonorchis sinensis

In Southeast Asia, biliary tract infections, bile stasis, bile duct fibrosis, and bile duct hyperplasia are among the factors that cause bile duct cancer. People who are accustomed to eating foods rich in nitrite are more likely to induce cancer.

3. Bile duct cystic dilatation

A small number of patients with bile duct cystic dilatation develop cancer. The formation of cysts and bacterial infections, especially the regurgitation of pancreatic juice due to abnormalities in the confluence area, are the main causes of canceration.

4. Primary sclerosing cholangitis

It has been reported that primary sclerosing cholangitis is a precancerous lesion of bile duct cancer.

Clinical manifestations of cholangiocarcinoma

Jaundice

Patients may develop jaundice, which is a progressive, persistent jaundice with pruritus and weight loss. A few patients without jaundice show upper abdominal pain, sometimes with fever and abdominal mass. Other symptoms include loss of appetite, nausea and vomiting, fatigue, and weight loss.

2. Two stools are abnormal

The stools are gray, white clay, dark yellow urine, such as strong tea.

3. Gallbladder enlargement

Patients with mid- and lower-stage cholangiocarcinoma may touch the enlarged gallbladder, but Murphy's sign may be negative; while hilar cholangiocarcinoma does not generally enlarge the gallbladder.

4. Liver damage

Decompensation of liver function may appear ascites, or edema of both lower limbs. Tumor invasion or compression of the portal vein can cause portal hypertension; patients with advanced stages may be complicated by hepatorenal syndrome.

5. Biliary infection

Patients can have biliary tract infections. The most common infections are E. coli, Streptococcus faecalis, and anaerobic bacteria. Endoscopy and interventional radiological examinations can induce or exacerbate biliary tract infections, with pain in the right upper abdomen, high chills, jaundice, and even shock.

6. Biliary bleeding

Such as cancer ulceration can lead to upper gastrointestinal bleeding, melena, positive fecal occult blood, and anemia.

Cholangiocarcinoma test

Laboratory inspection

Blood total bilirubin, direct bilirubin, alkaline phosphatase, and -glutamyltransferase can be significantly increased. Transaminase is generally mildly abnormal. This imbalance in the elevation of bilirubin and transaminase helps to distinguish it from viral hepatitis. Prothrombin time prolonged. CA19-9 and CEA may increase in some patients.

2. Imaging examination

Imaging studies can help define the diagnosis of cholangiocarcinoma, understand the presence of metastases, and assess whether the tumor can be removed.

(1) Ultrasound imaging examination

B-ultrasound is simple, fast, accurate, and less expensive. It can be found that: bile duct dilatation inside and outside the liver; Ultrasonography is the first choice for obstructive jaundice.

Endoscopic ultrasound can avoid the interference of intestinal gas, and the frequency of the ultrasound probe is high, which can more clearly and show extrahepatic bile duct tumors. It has high accuracy for deep and deep cholangiocarcinoma and hilar cholangiocarcinoma. Can also determine whether the regional lymph nodes are metastatic. Direct biliary angiography can be performed under guidance, and bile can be taken to determine CA19-9, CEA, and bile cytology. Under ultrasound guidance, the diseased tissue can be punctured for histological examination; bile can also be drawn for obstructive site examination for exfoliated cells.

(2) Percutaneous liver cholangiography (PTC)

PTC can clearly show the shape, distribution and obstruction of bile duct trees inside and outside the liver. This test is an invasive procedure. Postoperative bleeding and bile leakage are more common and serious complications.

(3) Endoscopic retrograde cholangiopancreatography (ERCP)

ERCP should not be used as a routine test for bile duct cancer, or even relatively contraindicated. For high-grade cholangiocarcinoma, percutaneous transhepatic choledochogram can show the location of cholangiocarcinoma, and the internal support catheter can be placed to reduce yellowing. ERCP has diagnostic significance for lower stage cholangiocarcinoma, which is helpful for distinguishing it from duodenal papillary tumor and pancreatic head cancer.

(4) CT examination

CT can accurately show the location and extent of bile duct dilatation and obstruction, and is more accurate in determining the nature of the lesion. Three-dimensional spiral CT bile duct imaging (SCTC) has a tendency to replace PTC and ERCP examinations.

(5) Magnetic resonance cholangiopancreatography (MRCP)

MRCP is a non-invasive biliary imaging technique. It can show the full picture of the intrahepatic bile duct tree, the location and scope of tumor obstruction, the presence or absence of liver parenchyma or liver metastasis.

(6) Radionuclide development scan

Using ^99m EHIDA for intravenous injection and continuous photography with a gamma camera, a dynamic image of the biliary tract can be obtained without harming the patient, and the method is simple.

(7) Selective hepatic arteriography and portal vein angiography

The main purpose is to understand the relationship between the portal vein and the hepatic artery and the tumor, as well as the involvement of the tumor, to help evaluate the resectability of the tumor before surgery. Digital subtraction angiography (DSA) can show the relationship between hepatic portal blood flow to the liver and tumors, which is of significance for the expansion of bile duct cancer.

Cholangiocarcinoma diagnosis

Cholangiocarcinoma can be considered based on clinical manifestations. Combining laboratory and imaging studies can further define the diagnosis. The development of imaging diagnosis has provided an effective means for the diagnosis of bile duct cancer.

Differential diagnosis of bile duct cancer

Differential diagnosis first considers common bile duct stones, which are characterized by paroxysmal biliary obstruction and triads unique to gallstone cholangitis; malignant obstructive jaundice is generally persistent. Malignant tumors at the lower end of the common bile duct are often accompanied by enlarged gallbladder cysts, while stone obstruction is rare. If the gallbladder is not enlarged, diseases such as primary bile duct sclerosis, drug-induced jaundice, and chronic active hepatitis should be ruled out clinically.

Cholangiocarcinoma treatment

Surgical treatment

The principle of treatment for cholangiocarcinoma is: surgical resection is the main method in early cases, followed by radiotherapy and chemotherapy to consolidate and improve the effect of surgical treatment. For advanced cases that cannot be removed, biliary drainage surgery should be performed to control biliary infections, improve liver function, reduce comorbidities, prolong life, and improve quality of life.

2. Radiation therapy

Surgical resection is the only radical treatment for cholangiocarcinoma. Adjuvant radiation therapy can only improve the survival rate of patients. After effective bile duct drainage for unresectable and locally metastatic cholangiocarcinoma, radiotherapy can improve the symptoms and prolong life. However, cholangiocarcinoma has always been considered a radiation insensitive tumor. The median survival of radiotherapy is generally reported to be 9-12 months.

3. Chemotherapy

Cholangiocarcinoma is not sensitive to chemotherapy. Cholangiocarcinoma is less sensitive to chemotherapy than other gastrointestinal tumors such as colon cancer. However, chemotherapy may relieve symptoms caused by bile duct cancer, improve the quality of life of patients, and may prolong survival.