Gall bladder and Biliary tree

Dr. Vivek Mangla

MBBS, MS(MAMC), FAIS, MCh (AIIMS), FACRSI (Gold Medallist), FAIS

Gall bladder and Biliary tree

Gall bladder stones and bile duct stones

In modern societies, gall bladder stone is a significant public health problem. These are either cholesterol stones or brown pigmented stones. Most commonly patients have severe abdominal pain. Jaundice and/or associated fever suggests complications from the stones and mandates urgent treatment. Such patients should undergo a simple surgery called laparoscopic cholecystectomy. Sometimes the stone moves out from gall bladder to the bile duct. These patients are managed either with a two stage endoscopic bile duct stone removal (ERCP) followed by a laparoscopic surgery for removal of gall bladder, or a single stage laparoscopic procedure entailing removal of gall bladder as well the stone in the bile duct. The advantages of the latter procedure, in experienced hands, are that it is a single stage treatment and avoid risks associated with ERCP namely pancreatitis, cholangitis, perforation or bleeding. We have performed laparoscopic Bile duct exploration in such patients with stent placement or choledochoduodenostomy. Patients go back home free of any stones and associated problems with no recurrence. A detailed & accurate understanding of endoscopic procedures like ERCP, MRCP etc. is required for the best & safest management of such patients with quick recovery.

In fact, sometimes gall bladder infections if ignored can proceed to complications like perforation or gangrene of gall bladder. Surgery in such situation needs more expertise and higher level of care. We have managed patients whose gall stones have passed into intestine and caused obstruction. Sometimes emergency surgery needed to done & special antibiotics given when gas forming bacteria lead to emphysematous gall bladder. Similarly empyema (pus) gall bladder also needs emergency surgery depending on severity of illness at the time of presentation. Diabetic patients are at higher risk of such complications.

Benign biliary stricture

Benign Biliary stricture, also referred to as bile duct stricture, occurs when the bile duct gets smaller or narrower. Patients with mild biliary strictures may not show any symptoms. When symptoms develop, they may include jaundice (yellowing of the skin), itching, and lightening of stool colour.

Most biliary strictures arise in the setting of surgery for complicated gall stone disease where in there is inadvertent injury to the bile duct (bile duct injuries occur in 0.1% patients undergoing laparoscopic cholecystectomy worldwide). Other causes include instrumentation of gall bladder or biliary tree, infections and congenital conditions like choledochal cyst. High quality imaging is of paramount importance in accurate understanding of biliary diseases. Improperly treated, bile duct strictures may lead to long term irreversible changes in liver (cirrhosis) resulting in portal hypertension and liver failure. Though early surgical repair (in 72 hours of injury) is more cost effective in experienced hands, a certain group of patients have benefited from delaying the repair for controlling infection and improving nutrition. Very high success rate of > 90% has been reported for these injury related strictures in trained hands and care centre. See a patient review and video for details. The best chance of cure is at first attempt at correction and it is paramount that the treating surgeon is experienced in dealing with these cases and working in a well-equipped facility.

Gall bladder cancer

There are three common clinical scenarios for gall bladder cancer

Identified at biopsy after routine cholecystectomy
Discovered Intraoperatively
Suspected before surgery

Careful history taking and examination can point towards early detection of gall bladder cancer. This is important because primary resection remains the best choice for a good outcome. If the stone size is big (>3cm) or calcified gall bladder is seen on ultrasound or CT scan, surgeons’ suspicion for gall bladder cancer should be heightened. The team should be prepared for a definitive operation at the first attempt itself. This curative operation usually involves removal of gall bladder with a small amount of surrounding liver &surrounding lymph nodes. In experienced hands and well equipped facilities, this surgery can be performed quite safely. For those patients, whose gall bladder cancer is incidentally detected in the biopsy specimen of a normally performed cholecystectomy, we perform a completion cholecystectomy. The decision for further treatment in cases of incidentally detected gall bladder cancer depends on the extent of disease in the removed gall bladder and imaging as well as a number of other factors.

Bile duct cancer

The cancer of bile duct is also called cholangiocarcinoma. When cancer affects the bile ducts which are still in the liver (intrahepatic ducts) it is called intrahepatic cholangiocarcinoma (bile duct cancer). While cancer affecting the part of the duct where it joins the intestine is known as distal bile duct cancer. Hilar cholangiocarcinoma is a form of bile duct cancer which afflicts confluence of right and left hepatic duct. Infact hilar cholangiocarcinoma or Klatskins tumor is the most common form of bile duct cancer. In the absence of effective chemotherapy or radiation therapy, surgical resection remains the mainstay of curative treatment. The ability to perform a margin-negative R0 complete resection is critical. Unfortunately, some patients present at a stage that is not amenable to surgical treatment. This requires careful surgical planning entailing good quality imaging, preoperative preparation (which may need interventional radiology procedures like PTBD and Portal vein embolization).

Choledochal cyst

Have you been diagnosed with choledochal cyst on ERCP or MRCP? Don’t panic. It has to be excised because of the risk of subsequently developing cancer. This surgery can be done laparoscopically with very good results. See my video for detailed understanding.

FAQ's

The gallbladder and biliary tree play crucial roles in the digestive system, aiding in the digestion and absorption of fats. However, various conditions can affect these organs, leading to health concerns such as bile duct cancer, gallbladder cancer, and choledochal cysts. This FAQs answered by one of the best GI & HPB Onco surgeons Dr. Vivek Mangla aims to provide comprehensive information on these topics, covering causes, symptoms, diagnosis, and treatment options.

What are the Biliary Tree and its Function?

The biliary tree is a network of tubes and ducts that transport bile from the liver to the small intestine. Bile produced by the liver, aids in the digestion and absorption of fats. The biliary tree includes the hepatic ducts, common bile duct, gallbladder, and cystic duct. Understanding its function is crucial in comprehending conditions related to these structures.

What is Bile Duct Cancer?

Bile duct cancer, also known as cholangiocarcinoma, is a rare but aggressive cancer that forms in the bile ducts.

Causes:

Chronic Inflammation: Conditions like primary sclerosing cholangitis (PSC) can lead to chronic inflammation of the bile ducts, increasing the risk of cancer.
Bile Duct Cysts: Caroli disease, a rare congenital disorder causing bile duct dilation, may elevate the risk.
Liver Fluke Infection: In regions where liver flukes are prevalent, such as Southeast Asia, infection can contribute to bile duct cancer.

Symptoms of Bile Duct Cancer:

Jaundice: Yellowing of the skin and eyes.
Abdominal Pain: Particularly in the upper right side.
Unexplained Weight Loss: A common symptom in many cancers.
Itching: Caused by the accumulation of bile salts under the skin.

Diagnosis of Bile Duct Cancer:

Imaging Tests: CT scans, MRIs, and endoscopic retrograde cholangiopancreatography (ERCP) can visualize the bile ducts.
Biopsy: A sample of tissue is examined for cancer cells.
Blood Tests: Elevated levels of certain enzymes may indicate bile duct obstruction.

Treatment of Bile Duct Cancer:

Surgery: If possible, surgeons may remove the tumor or affected parts of the bile duct.
Liver Transplant: In advanced cases, a liver transplant may be considered.
Chemotherapy and Radiation: Used to shrink tumors before surgery or to control symptoms.

What is the main cause of bile duct cancer ?

Bile duct cancer, also known as cholangiocarcinoma, can have various causes, and in many cases, the exact cause is not clear. However, certain risk factors are associated with an increased likelihood of developing bile duct cancer.

Primary Sclerosing Cholangitis (PSC): This is a chronic inflammatory disease of the bile ducts that increases the risk of developing bile duct cancer.
Chronic Biliary Inflammation: Conditions such as chronic biliary infections or inflammation can contribute to the development of cancer over time.
Liver Fluke Infection: In some parts of the world, infection with liver flukes (parasitic flatworms) has been linked to an increased risk of bile duct cancer.
Biliary Stone Disease: Long-standing issues with gallstones or bile duct stones may lead to chronic irritation and inflammation, potentially increasing the risk.
Choledochal Cysts: These are congenital abnormalities of the bile ducts that can increase the risk of cancer development.
Age and Gender: Bile duct cancer is more common in older adults, and there is a slightly higher incidence in men compared to women.
Cirrhosis: Chronic liver diseases, such as cirrhosis, may contribute to the development of bile duct cancer.
Smoking: Tobacco use has been identified as a potential risk factor for bile duct cancer.
Chemical Exposure: Exposure to certain chemicals or toxins may increase the risk of developing bile duct cancer, although the specific substances involved can vary.

It's important to note that the interplay of various factors can contribute to the development of cancer, and individual cases may have unique combinations of risk factors. Early detection and diagnosis are crucial for improving outcomes, as bile duct cancer is often diagnosed at an advanced stage. If you have concerns about your risk or symptoms related to bile duct cancer, it's recommended to consult with a healthcare professional for personalized advice and appropriate screening.

What are the signs of cancer of the bile duct ?

Bile duct cancer, also known as cholangiocarcinoma, may not cause noticeable symptoms in its early stages. However, these symptoms are not specific to bile duct cancer and can also be associated with other conditions. If you experience persistent or worsening symptoms, it's important to consult with a healthcare professional for a thorough evaluation.

Jaundice: Yellowing of the skin and eyes is a common symptom of bile duct obstruction. This occurs when the cancer blocks the flow of bile, leading to a buildup of bilirubin in the body.
Abdominal Pain: Pain in the upper right side of the abdomen or around the liver area may occur as the tumor grows and affects surrounding tissues.
Unexplained Weight Loss: Significant and unexplained weight loss can be a symptom of various cancers, including bile duct cancer.
Itching (Pruritus): Bile duct obstruction can lead to the accumulation of bile salts in the skin, causing itching.
Dark Urine: Bilirubin, which is not properly excreted due to bile duct obstruction, can give urine a dark color.
Light-Colored Stools: Bile gives stool its normal brown color. When bile flow is obstructed, stools may become pale or clay-colored.
Fever and Chills: In some cases, infection within the bile ducts may occur, leading to fever and chills.
Fatigue: Persistent fatigue and weakness can be associated with various cancers, including bile duct cancer.

It's important to note that these symptoms can be caused by conditions other than bile duct cancer. Additionally, early-stage bile duct cancer may not cause noticeable symptoms. Due to the non-specific nature of these symptoms, a thorough medical evaluation is necessary to determine the cause and appropriate course of action.

If you are experiencing any of these symptoms or have concerns about your health, it's crucial to seek medical attention promptly. Your healthcare provider may perform imaging studies, blood tests, and other diagnostic procedures to assess your condition and identify the underlying cause of your symptoms.

Can bile duct cancer be cured?

The prognosis for bile duct cancer (cholangiocarcinoma) can vary based on several factors, including the stage at which the cancer is diagnosed, the location of the tumor, and the overall health of the individual. Bile duct cancer is often challenging to treat, and the potential for a cure depends on the extent of the disease and the feasibility of surgical intervention.

Surgery: In some cases, surgical removal of the tumor may offer a chance for cure, particularly if the cancer is detected at an early stage and is confined to a localized area. However, the feasibility of surgery depends on factors such as the tumor's size, location, and whether it has spread to surrounding tissues or organs.
Liver Transplant: In select cases, liver transplantation may be considered as a treatment option, especially for individuals with certain types of bile duct cancer and limited tumor involvement. However, suitable candidates for liver transplantation are carefully evaluated.
Chemotherapy and Radiation Therapy: For individuals with unresectable or advanced bile duct cancer, chemotherapy and/or radiation therapy may be recommended to help shrink tumors, alleviate symptoms, and slow the progression of the disease. While these treatments may not provide a cure in advanced cases, they can extend survival and improve quality of life.
Palliative Care: In cases where the cancer is advanced and a cure is not achievable, palliative care aims to manage symptoms, improve quality of life, and provide emotional support.

The overall prognosis for bile duct cancer tends to be less optimistic compared to some other types of cancer, primarily due to the late stage at which it is often diagnosed. Early detection is crucial for a better chance of curative treatment. Regular medical check-ups, imaging studies, and blood tests may be recommended for individuals with risk factors or symptoms associated with bile duct cancer.

It's important for individuals diagnosed with bile duct cancer to work closely with a multidisciplinary healthcare team, including oncologists, surgeons, and other specialists, to determine the most appropriate treatment plan based on the specific characteristics of their cancer. Advances in research and treatment continue, and clinical trials may offer additional options for some patients.

What is Gallbladder Cancer?

Gallbladder cancer is an uncommon but aggressive cancer that forms in the tissues of the gallbladder.

Causes:

Gallstones: Long-term presence of gallstones can increase the risk.
Chronic Inflammation: Conditions like chronic gallbladder inflammation (cholecystitis) may elevate the risk.

Symptoms:

Abdominal Pain: Particularly in the upper right side.
Jaundice: Yellowing of the skin and eyes.
Unexplained Weight Loss: A common symptom in many cancers.
Nausea and Vomiting: Especially after meals.

Diagnosis:

Imaging Tests: CT scans, MRIs, and ultrasound can visualize the gallbladder.
Blood Tests: Elevated levels of certain enzymes may indicate gallbladder issues.

Treatment:

Surgery: Removal of the gallbladder (cholecystectomy) is the primary treatment.
Chemotherapy and Radiation: Used in advanced cases or to shrink tumors before surgery.
Targeted Therapy: Drugs targeting specific molecules involved in cancer growth.

What are Choledochal Cysts?

Choledochal cysts are congenital cystic dilations of the bile ducts.

Causes:

Congenital Factors: Anomalies in the development of the bile ducts during fetal growth.
Genetic Predisposition: Some cases may have a familial association.
Environmental Factors: Exposure to certain toxins or infections during pregnancy may contribute.

Symptoms:

Abdominal Pain: Particularly in the upper right side.
Jaundice: Yellowing of the skin and eyes, often occurring in infants.
Enlarged Abdomen: Due to cystic dilation.

Diagnosis:

Imaging Tests: Ultrasound, CT scans, and MRIs can visualize the cysts.
Endoscopic Retrograde Cholangiopancreatography (ERCP): A procedure to examine and treat issues in the bile ducts.

Treatment:

Surgery: The cyst is typically removed to prevent complications such as infection or cancer development.
Follow-up Care: Regular monitoring is essential, especially if any part of the cyst remains.

Prevention and Outlook:

Prevention:

Maintain a Healthy Lifestyle: This includes a balanced diet, regular exercise, and avoiding excessive alcohol consumption.
Prompt Treatment of Gallstones: Addressing gallstones promptly can reduce the risk of gallbladder and bile duct cancers.

Outlook:

Early Detection: Early diagnosis and intervention significantly improve the prognosis for bile duct cancer, gallbladder cancer, and choledochal cysts.
Advancements in Treatment: Ongoing research and advancements in medical science continue to enhance treatment options and outcomes.

Understanding the intricacies of the gallbladder and biliary tree is crucial for recognizing and addressing potential health issues. Bile duct cancer, gallbladder cancer, and choledochal cysts are complex conditions that require a multidisciplinary approach for diagnosis and treatment. As medical science progresses, there is hope for improved outcomes and a better understanding of these conditions, ultimately leading to more effective prevention and management strategies. If you suspect any issues related to your gallbladder or bile ducts, it is essential to consult with a healthcare professional for timely evaluation and appropriate care.

Gall bladder and Biliary tree