The gallbladder is a small, pear-shaped pouch that lies beneath the liver, in the upper abdomen. It stores bile. This fluid, produced by the liver, helps digest fat. The gallbladder releases bile into the small intestine through the bile duct. This thin tube connects the liver and gallbladder to the small intestine. Cancer develops when abnormal cells in these structures multiply and grow rapidly.
Most gallbladder and bile duct cancers are adenocarcinomas -- cancers of cells that line the glands and ducts. Bile duct adenocarcinoma forms from the mucus glands that line the duct. It can develop in any part of the bile duct.
Gallbladder and bile duct cancers are rare. Gallbladder cancer is more common in women than in men. People with gallstones have a slightly higher risk of developing gallbladder and bile duct cancer. These cancers also have been linked to infections with the liver fluke parasite. They have also been tied to sclerosing cholangitis, ulcerative colitis and cirrhosis. These diseases can cause inflammation and scarring of the bile duct, colon or liver.
Early on, gallbladder and bile duct cancers may cause no symptoms. Nor can they be seen or felt during a routine physical exam. Rather, many of them are found when the gallbladder is removed as a treatment for gallstones. There are no screening tests for these cancers.
When symptoms occur, they can include:
- abdominal pain or swelling
- nausea and/or vomiting
- lack of appetite
- losing weight for no reason
- fever that doesn't go away
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 makes the skin and the whites of the eyes look yellow. This happens when the liver cannot get rid of bile. Levels of bilirubin (a dark yellow chemical in bile) then rise in the bloodstream. Bile and bilirubin can also cause itching.
Although many people with gallbladder and bile duct cancers have jaundice, the most common cause of jaundice is hepatitis, not cancer. Having a gallstone lodged in the bile duct can also cause jaundice; it can prevent bile from flowing into the small intestine. This is a noncancerous condition.
Your doctor will ask about your medical history and examine you, focusing on your abdomen. He or she will check for masses, tender spots, fluid build-up and enlarged organs. In addition, your doctor will check your skin and eyes for jaundice and feel lymph nodes for swelling.
Next, you will have blood tests. These tests can measure the levels of liver and gallbladder enzymes, and of bilirubin. Too much bilirubin in the blood may mean that your bile duct is blocked or that you have gallbladder or liver problems. An elevated level of an enzyme called alkaline phosphatase also can point to a blocked bile duct or gallbladder disease. A substance called CA 19-9 may be elevated in people with bile duct cancer.
But blood tests cannot determine why levels of these substances are elevated. To do that, your doctor may order one or more of these tests:
- Ultrasound. Ultrasound uses sound waves to make pictures of internal organs. It can detect about half of gallbladder cancers. It can also help find a bile duct obstruction or tumor, if it's large enough.
Ultrasound can be combined with endoscopy and laparoscopy. During endoscopy, your doctor inserts a flexible viewing tube (an endoscope) into your mouth. He or she then feeds the tube through the stomach and into the first part of the small intestine, where the bile duct empties. Laparoscopy is a limited type of surgery. It 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. This placement produces 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 determine whether the tumor has spread to the bile duct, liver or nearby lymph nodes.
- Magnetic resonance imaging (MRI). These scans also create cross-sectional images of internal organs. However, they use radio waves and powerful magnetic fields instead of radiation. They can make more detailed images than ultrasounds and CT scans. That's why they are effective in showing whether a tumor is only in the gallbladder or has invaded the liver. A special type of magnetic resonance imaging -- magnetic resonance cholangiopancreatography (ko-LAN-gee-o-PAN-cree-a-TOG-ruh-fee) (MRCP) -- creates pictures that make the bile duct stand out. It's among the best noninvasive ways to check for bile duct cancer.
- 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. These pictures can show if the bile duct is narrowed or blocked. The advantage of ERCP is that it can be used to take biopsies of a blocked area and relieve the blockage. To do this, the doctor places a wire-mesh tube, called a stent, in the bile duct to keep it open. Sometimes, inserting a stent eliminates the need for surgery.
- Surgery. Sometimes surgery must be done to determine if there is cancer in the gallbladder or bile duct.
- Biopsy. To be certain of the diagnosis, a tissue sample will be taken from the tumor or mass and examined in a laboratory. Bile may be taken to see if it contains cancer cells. Tissue and bile samples can be taken during an ERCP, with a needle guided by a CT scan, by scraping the lining of ducts with a small brush, 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, you can lower your risk of gallbladder cancer by maintaining a healthy weight and avoiding tobacco.
Preventing and treating liver fluke infections may help to reduce the risk of bile duct cancer. To do this:
- Cook or freeze freshwater fish from Asia before eating it.
- Purchase shellfish only from reputable stores.
- Take medication as prescribed if you are diagnosed with a liver fluke infection.
Preventing hepatitis may also reduce the risk of bile duct cancer. To do this:
- Practice safer sex by using condoms.
- Do not inject illegal drugs. If you do, never share needles with anyone.
- Ask your doctor about getting vaccines against hepatitis A and B. There is no vaccine against other forms of hepatitis.
If you have been exposed to someone with hepatitis A or B, talk to your doctor about getting the vaccine or an immunoglobulin shot as soon as possible.
If you have an inflammatory bowel disease, such as ulcerative colitis, you have an increased risk of gallbladder and bile duct cancers. Your doctor may evaluate you for these cancers during routine exams.
Treatment will depend on:
- the type, location, and extent of your cancer
- your overall health
- the chances of curing the disease, extending your life or relieving symptoms
Because gallbladder and bile duct cancers are rare, get a second opinion before deciding on a treatment. Seek treatment at a medical center with a staff that is expert in treating your type of cancer.
Surgery is the main treatment for gallbladder and bile duct cancers. Surgery is the only possible way to cure the disease, but opinions vary as to how advanced a gallbladder or bile duct cancer can be and still be curable. Because there usually are no symptoms early on, these cancers are often fairly advanced when they are discovered. Surgery for gallbladder and bile duct cancer is difficult for both doctors and patients. Unless there is clear evidence that the procedure is likely to significantly extend your life or improve your 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. This procedure restores the flow of bile. The surgeon can insert a biliary stent or catheter (tube) to release bile into the small intestine or externally. Biliary stents also can be placed without surgery. A doctor can guide an endoscope from your mouth into your stomach and 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 beam radiation directs X-ray beams at the cancer from a machine outside the body.
- Brachytherapy involves putting radioactive material in the body, near the tumor.
Radiation may be used after surgery to kill any remaining cancer cells. If the cancer has spread too far to be removed completely, it may be the primary treatment. However, radiation therapy cannot cure these cancers.
For advanced cases, radiation also may be used as palliative therapy. That means the goal is not to cure the cancer, but to reduce pain or other symptoms by shrinking the tumor.
If you have bile duct cancer, your doctor might also recommend chemotherapy. Chemotherapy involves the use of drugs -- taken by mouth or injected into a vein -- to kill cancer cells. Chemotherapy can help shrink a bile duct tumor before surgery. It can also help control symptoms when surgery is not recommended or the tumor has advanced despite other treatments.
Gallbladder cancer does not respond very well to chemotherapy.
In advanced stages of gallbladder cancer, treatment response can sometimes be assessed with tumor markers. Blood tests for CA 19-9 and CEA can be done prior to starting treatment. If one or both levels are high and decrease after cancer therapy, this usually indicates shrinking of the cancer.
You should see your doctor if you have:
- jaundice (yellowing of the skin and whites of the eyes)
- persistent itching
- persistent abdominal pain
- weight loss for no known reason
- a fever that won't go away
All of 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 your general health, how far the cancer has spread and the type of treatment. In the earlier stages of gallbladder and bile duct cancer, when surgery can be done, between 15% and 50% of patients survive at least 5 years. When the tumor is advanced and surgery is not possible, the 5-year survival rate is much lower. Unfortunately, this is when many gallbladder and bile duct cancers are diagnosed.
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