Bile Duct Cancer

Overview:
Bile duct cancer (Cholangiocarcinoma) is a malignancy arising from the cells that line the bile ducts. This results in narrowing and obstruction of the liver’s drainage system.
The cancer can occur in the ducts within the liver (intrahepatic ducts) or in the ducts that connect the liver to the small intestine (common hepatic duct and common bile duct).

Symptoms:

The obstruction rarely causes pain but frequently causes yellowing of the eyes and skin (jaundice), itching, and weight loss.

Testing:

The diagnosis is suspected when blood tests reveal abnormally elevated liver enzymes and an imaging study such as ultrasound, CT scan, or MRI scan demonstrates swelling or dilatation of the bile ducts above the obstructing cancer.

The diagnosis can be confirmed by performing an MRI scan of the bile ducts (MRCP) that will demonstrate an area of obstruction and a possible mass lesion. Endoscopic Retrograde Cholangiopancreatography (ERCP) can also be performed to confirm the diagnosis, obtain biopsies and relieve the obstruction.

After the patient is deeply sedated, the physician passes a flexible tube (endoscope) through the mouth, esophagus, and stomach and into the beginning of the small intestine called the duodenum. At this location, the bile duct drains into the intestine through a small nipple-like opening called the papilla. A plastic tube called a catheter is then passed through the scope, into the papilla and up into the bile duct. Contrast material is then injected into the ducts and images are obtained using an X-ray machine. A brush can be passed into the narrowing of the bile duct to obtain a tissue specimen to confirm the diagnosis of cancer. A plastic or metal tube called a stent can also be placed across the narrowing to relieve the obstruction.

Treatment:

Definitive treatment options include surgery to remove and possibly cure the cancerous growth, or chemotherapy/radiation therapy to shrink it.

Bile Duct Stricture

Overview:
Bile duct stricture is a narrowing of the bile ducts, the tubes that drain the liver into the small intestine. A stricture can occur in the ducts within the liver (intrahepatic ducts) or in the ducts that connect the liver to the small intestine (common hepatic duct and common bile duct).

A stricture may be benign and related to scarring from previous surgery or an uncommon condition call primary sclerosing cholangitis (see separate discussion). It may also be malignant due to a cancerous growth arising from the cells that line the bile duct (cholongiocarcinoma) or from a cancerous growth in an adjacent organ compressing the duct, most commonly pancreatic cancer.

Cancerous growths within the liver or the lymph nodes beneath the liver can also cause obstruction of the bile ducts. The diagnosis is suspected when blood tests reveal abnormally elevated liver enzymes and an imaging study such as ultrasound, CT scan, or MRI scan demonstrates swelling or dilatation of the bile ducts above the narrowed duct.

Symptoms:

The obstruction rarely causes pain but frequently causes yellowing of the eyes and skin (jaundice) and itching.

Testing:

The diagnosis can be confirmed by performing an MRI scan of the bile ducts (MRCP) which will demonstrate an area of obstruction. Endoscopic Retrograde Cholangiopancreatography (ERCP) can also be performed to confirm the diagnosis, obtain biopsies and relieve the obstruction.

Treatment:

A stricture can be treated during ERCP by inflation a balloon in the area that is narrowed. A plastic or metal stent may also be placed temporarily to prevent the stricture from recurring. A persistant or recurring stricture may require surgery.

Cholecystitis

Overview:
Cholecystitis is inflammation of the gallbladder, a small sac that sits under the liver and stores bile after it is produced by the liver.

Gallstones are formed in the gallbladder from cholesterol and other material found in bile. A high concentration of cholesterol in bile and conditions such as pregnancy, which interfere with normal gallbladder emptying, promote gallstone formation.

Gallstones may be tiny or as large as a golf ball.

Symptoms:

Gallstones are quite common and most people will have no symptoms. When gallstones obstruct the flow of bile from the gallbladder pain will occur.

Cholecystitis occurs when a stone travels out of the gallbladder and becomes trapped in the cystic duct, the tube that drains the gallbladder. This causes the gallbladder to swell and become infected by bacteria.

Symptoms of cholecystitis include pain in the right upper abdomen, fever, nausea, and vomiting.

Testing:

The diagnosis is made by a history of typical symptoms, physical examination, blood tests, and an imaging study of the abdomen such as an ultrasound.

The obstruction of the cystic duct can be confirmed by a nuclear medicine test known as a HIDA scan which evaluates gallbladder function.

Treatment:

Treatment for Cholecystitis usually consists of antibiotics and surgical removal of the diseased gallbladder.

Common Bile Duct Stone

Overview:
Common bile duct stone (also known as choledocholithiasis) is the presence of a gallstone in the common bile duct, the tube that drains the liver and gallbladder into the small intestine.

The gallbladder is a small sac that sits under the liver and stores bile after it is produced by the liver.

After a meal the gallbladder contracts and empties bile through cystic duct and bile ducts (tubes) into the small intestine to help digest fats. Gallstones are formed in the gallbladder from cholesterol and other material found in bile. A high concentration of cholesterol in bile and conditions such as pregnancy that interfere with normal gallbladder emptying promote gallstone formation.

Gallstones may be tiny or as large as a golf ball.

Occasionally a gallstone will travel out of the gallbladder and become lodged in the common bile duct. It will not pass spontaneously into the small intestine because of the sphincter muscle at the end of the common bile duct.

Symptoms:

The obstructing stone will cause pain in the upper abdomen. If infection ensues (cholangitis) the patient will also complain of fever and severe chills.

A stone trapped in the bile duct is suspected when an ultrasound reveals gallbladder stones and blood tests reveal abnormally elevated liver enzymes. On ultrasound the bile duct may also be enlarged or swollen due to the obstruction.

Testing:

The diagnosis can be confirmed by performing an MRI scan of the bile ducts (MRCP) that will demonstrate the stone in the duct.

Treatment:

A common bile duct stone can be removed by performing Endoscopic Retrograde Cholangiopancreatography (ERCP).

After the patient is deeply sedated, the physician passes a flexible tube (endoscope) through the mouth, esophagus and stomach and into the beginning of the small intestine called the duodenum. At this location, the bile duct drains into the intestine through a small nipple-like opening called the papilla. A plastic tube called a catheter is then passed through the scope, into the papilla and up into the bile duct. Contrast material is then injected into the ducts and images are obtained using an X-ray machine.

After the presence of a stone is confirmed a small incision is made through the sphincter muscle using a wire attached to the side of the catheter. The stone can then be pulled out of the duct into the small intestine.

Although generally safe, ERCP can cause complications such as pancreatitis, infection and intestinal perforation or bleeding.

Gallbladder Stones

Overview:
The gallbladder is a small sac that sits under the liver and stores bile after it is produced by the liver.

After a meal, the gallbladder contracts and empties bile through the cystic duct (tube) and bile ducts into the small intestine to help digest fats.

Gallstones are formed in the gallbladder from cholesterol and other material found in bile. A high concentration of cholesterol in bile and conditions such as pregnancy, which interfere with normal gallbladder emptying, promote gallstone formation.

Gallstones may be tiny or as large as a golf ball.

Symptoms:

Gallstones are quite common and most people will have no symptoms.

When gallstones obstruct the flow of bile from the gallbladder, pain will occur. The pain can be quite severe and is typically located in the right upper abdomen. The pain may travel into the right shoulder blade. These attacks are often associated with nausea and vomiting and typically occur after eating, particularly fatty meals. Most attacks will resolve within hours.

Other complications from gallstones including cholecystitis, common bile duct stones, and pancreatitis, are discussed separately.

Testing:

Gallstones can easily be diagnosed by an ultrasound test of the gallbladder.

Treatment:

Gallstones that do not cause symptoms require no treatment. When symptoms are present, the gallbladder should be removed surgically.

Sphincter of Oddi Dysfunction

Overview:
Sphincter of Oddi dysfunction refers to abnormal function of the sphincter muscle at the end of the bile and pancreatic ducts, the tubes that drain the liver and pancreas into the small intestine through a small nipple-like opening called the papilla.

The sphincter is a circular band of muscle tissue that controls the release of bile and pancreatic juices though an opening in the papilla into the intestine. Abnormal relaxation of the sphincter prevents normal flow of bile or pancreatic juices into the intestine.

Symptoms:

Sphincter of Oddi dysfunction may cause episodic upper abdominal pain and even pancreatitis (see separate discussion under pancreatic disorders).

Testing:

The diagnosis is considered in patients with typical pain and abnormally elevated liver enzymes in the absence of gallstones or other causes of bile duct obstruction. The diagnosis should also be considered in patients with repeated and unexplained episodes of pancreatitis.

The diagnosis can be confirmed by Endoscopic Retrograde Cholangiopancreatography (ERCP). After the patient is deeply sedated, the physician passes a flexible tube (endoscope) through the mouth, esophagus and stomach and into the beginning of the small intestine called the duodenum. At this location the bile duct drains into the intestine through a small nipple-like opening called the papilla. A plastic tube called a catheter is then passed through the scope, into the papilla and up into the bile duct. The pressure within the sphincter can be assessed. An elevated sphincter pressure is suggestive of sphincter dysfunction.

Treatment:

Treatment consists of cutting the sphincter muscle (sphincterotomy) during ERCP using a thin wire attached to a catheter. ERCP and sphincterotomy are associated with a significant risk of a complication called pancreatitis when performed on patients with Sphincter of Oddi dysfunction or in patients suspected to have the condition.