The gallbladder is a small, pear-shaped organ situated under the liver in the upper abdomen. It stores bile, a fluid produced by the liver that helps to digest fat. The gallbladder releases bile into the small intestine during digestion through the bile duct, a thin tube that connects the liver and gallbladder to the small intestine. Cancer is the uncontrolled growth of abnormal cells.

According to the American Cancer Society, 80 percent of gallbladder cancers and 95 percent of bile duct cancers are adenocarcinomas, which are cancers of cells that line the glands and ducts. Bile duct adenocarcinoma (also known as cholangiocarcinoma) forms from the mucus glands that line the ducts and can develop in any part of the bile duct.

Cancers of the gallbladder and bile ducts are rare. The American Cancer Society estimates that each year approximately 3,000 people in the United States develop bile duct cancer, and 6,000 to 7,000 new cases of gallbladder cancer are diagnosed. Gallbladder cancer is more common in women than in men, and people with gallstones are at a slightly higher risk of developing gallbladder or bile duct cancer. Bile duct cancers are more common in Asia. They also have been associated with infections with the liver fluke parasite, sclerosing cholangitis, ulcerative colitis and cirrhosis.

In their early stages, gallbladder and bile duct cancers often do not cause any symptoms. Many of these cancers are found when the gallbladder is removed as a treatment for gallstones. Early tumors cannot be seen or felt during a routine physical examination, and there are no screening tests for these cancers.

Gallbladder and bile duct cancer can cause the following symptoms:

• Jaundice – Jaundice is the most common symptom of bile duct cancer, and nearly half of all people with gallbladder cancer have jaundice when they are diagnosed. Jaundice gives the skin and the whites of the eyes a yellow tint. It is caused when the liver cannot get rid of bile, causing levels of bilirubin (a dark yellow chemical in bile) to rise in the bloodstream. Bile and bilirubin can also cause itching. Although many people with gallbladder and bile duct cancers have jaundice, the most frequent cause of jaundice is hepatitis, not cancer.



• Abdominal pain – Pain related to the gallbladder often occurs in the upper right part of the abdomen.



• Nausea, vomiting or both



• General symptoms – These can include loss of appetite, weight loss, fever and abdominal swelling.

Your doctor will ask you about your medical history and do a physical examination. The examination will focus mainly on the abdomen. Your doctor will check for masses, areas of tenderness, fluid accumulation and enlarged organs. In addition, your doctor will check your skin and eyes for jaundice and your lymph nodes at various locations for swelling.

You may be given the following tests:

• Blood chemistry tests – Laboratory tests can measure the levels of liver and gallbladder enzymes, and of bilirubin, which is the chemical in bile that gives it its color. Too much of it in the blood indicates that the bile duct might be blocked, or there might be gallbladder or liver problems. An elevated level of alkaline phosphatase also can point to bile duct obstruction or gallbladder disease. Blood tests cannot determine, however, if elevated levels of these substances are caused by cancer or by some other condition.



• Ultrasound – Ultrasound detects about one-half of gallbladder cancers, and also can help to find a bile duct obstruction or tumor if the mass is large enough. Ultrasound uses sound waves to make images of internal organs. Ultrasound also can be used in combination with endoscopy and laparoscopy. These procedures are needed only in certain cases. In endoscopy, a flexible viewing tube called an endoscope is inserted into the mouth, through the stomach and into the first part of the small intestine where the bile duct empties. Laparoscopy is a limited type of surgery that involves placing a surgical instrument called a laparoscope through a small cut on the side of the body. Both procedures allow the ultrasound transducer to be placed closer to the gallbladder, producing more detailed images than a standard ultrasound.



• Computed tomography (CT) – This test uses a rotating X-ray beam to make detailed, cross-sectional images of the body. A CT scan can identify a tumor inside the gallbladder or one that has spread outside of it. It also can help to evaluate whether the tumor has spread to the bile duct, liver or nearby lymph nodes.



• Magnetic resonance imaging (MRI) and MRCP – These scans also create cross-sectional images of internal organs, but use radio waves and powerful magnetic fields instead of radiation. They can make more detailed images than ultrasounds and CT scans, and are effective in showing whether a tumor is only in the gallbladder or has invaded the nearby liver. A special type of magnetic resonance imaging – magnetic resonance cholangiopancreatography (MRCP) – makes pictures that make the bile ducts stand out, and is considered among the best noninvasive ways to test for bile duct cancer. A biopsy still will be needed to confirm the diagnosis, however.



• Endoscopic retrograde cholangiopancreatography (ERCP) – In this procedure, a flexible tube is passed down the throat, through the esophagus and stomach, and into the common bile duct. A small amount of contrast dye is used to help outline the bile duct in X-ray images, which can show if the bile duct is narrowed or blocked. The advantage of ERCP is that the same instrument also can be used to take biopsies of a blocked area. A blockage also can be relieved by placing a device called a stent during ERCP, which can sometimes avoid the need for surgery. A stent is a wire-mesh tube that helps to keep the bile duct open.



• Surgery – Sometimes surgery must be done to determine if there is cancer in the gallbladder or bile duct.



• Biopsy – Ultimately, to be certain of the diagnosis, a sample of tissue will be taken from the tumor or mass to be examined in a laboratory. A sample of tissue can be taken during an ERCP, with a needle guided by a CT scan, or during surgery.

Gallbladder and bile duct cancers will continue to grow unless treated.

There is no way to prevent gallbladder or bile duct cancers. However, some risk factors for gallbladder cancer can be controlled to lower your chance of developing the disease. You should maintain a healthy body weight and avoid smoking.

Preventing and treating liver fluke infections and hepatitis may help to reduce the risk of bile duct cancer. To do this:

• Cook or freeze freshwater fish from or while in Asia to prevent liver fluke infections.
• Purchase shellfish only from reputable stores.
• To prevent hepatitis B and C, practice safer sex with condoms.
• Do not inject illegal drugs. If you do, never share needles with anyone.

Vaccines are available for hepatitis A and B. If you have been exposed to someone with hepatitis B, talk to your doctor about getting either an immunoglobulin shot or the vaccine as soon as possible.

The treatment plan will depend on the type, location and stage of the cancer; the person's overall health; and the likelihood of curing the disease, extending the person's life or relieving symptoms. Because gallbladder and bile duct cancers are uncommon, you should consider getting a second opinion before deciding on a treatment plan.

• Surgery is the main treatment for gallbladder and bile duct cancers. Although doctors agree that surgery is the only possible way to cure the disease, opinions vary as to how advanced a gallbladder or bile duct cancer can be and still be curable. Because there usually are no symptoms in the disease's early stage, cancers are often fairly advanced when they are discovered. Surgery for gallbladder and bile duct cancer is difficult and hard on the patient, so unless there is clear evidence that the procedure is likely to extend survival significantly or improve the quality of life, it may not be the best option. However, surgery sometimes can help to relieve pain or prevent complications. This type of "palliative surgery" includes a biliary bypass to restore the flow of bile, or insertion of a biliary stent or catheter (tube) to release bile into the small intestine or externally. Biliary stents also can be placed without surgery, through an endoscope that is guided in through the mouth, into the stomach and then the small intestine, where the bile duct opening can be reached.
  
  
• Radiation therapy also can be used to treat gallbladder and bile duct cancers. There are two types of radiation therapy. External radiation uses X-ray beams from a machine outside the body to kill cancer cells. In brachytherapy, radioactive material is placed inside the body where the cancer is. Radiation may be used as additional therapy after surgery to kill any remaining cancer cells, or as the main therapy when the cancer has spread too far to be removed completely by surgery. However, radiation therapy cannot cure such patients. For advanced cases, radiation also may be used as palliative therapy, which means the main purpose is to reduce pain or other symptoms by shrinking the tumor.
  
  
• Chemotherapy, in which anticancer drugs are administered into a vein or taken by mouth, is likely to be used for bile duct cancers to help shrink the tumor before surgery or as palliative therapy to control symptoms when surgery is not recommended or the tumor has advanced despite other treatments. Gallbladder cancer does not respond as well to chemotherapy.

You should see your doctor if you have jaundice (yellowing of the skin and whites of the eyes), persistent itching of the skin, persistent pain in the abdomen, weight loss without trying or a fever that won't go away. All these symptoms can be related to noncancerous diseases, but you should visit your doctor so that your condition can be diagnosed and treated as soon as possible.

The outlook depends on the person's general health, how far the cancer has spread by the time it is diagnosed, and the type of treatment. Gallbladder and bile duct cancers usually are diagnosed when the disease is advanced and causes symptoms, and, therefore, the survival rate is low. In the earlier stages of gallbladder and bile duct cancer, when resection can be attempted, between 15 percent and 50 percent of patients survive 5 years or more. When the tumor is in a later stage at diagnosis and resection cannot be attmpted, fewer than 5 percent of patients survive 5 years or more.

American Cancer Society (ACS)
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National Cancer Institute (NCI)
U.S. National Institutes of Health
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Bethesda, MD 20892-2580
Phone: 301-435-3848
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http://www.nci.nih.gov/