Bile duct cancer diagnosis

Diagnosis

If a carcinoma of the bile ducts is suspected, the patient is first interviewed in detail (anamnesis). The symptoms that indicate a bile stasis will be investigated in particular. Then the patient is physically examined.

The first thing that is often noticeable is a yellowing of the skin (icterus). In some cases, if the tumor blocks the gallbladder duct, the examiner may palpate a painless, bulging gallbladder in the right upper abdomen (Courvoisier ́sches sign). In advanced cases, the actual tumor may become palpable.

When analyzing the blood (laboratory), certain blood values may indicate a disease of the bile ducts. For example, gamma-glutamyl transferase (gamma-GT), alkaline phosphatase (AP) and bilirubin may be elevated, which indicates a build-up of bile but is not specific to bile duct cancer. These blood parameters may also be elevated in other bile duct obstructions, such as a gallstone.

So-called tumor markers are substances in the blood that are found in high concentrations in some types of cancer and can thus indicate the presence of cancer. They do not play a significant role in the initial diagnosis of gallbladder carcinoma, as false-positive results can often be obtained. If, however, a certain tumor marker value is found to be elevated before surgery, which disappears after surgery, this marker can be used particularly well to detect a new onset of the tumor (tumor recurrence).

Tumour markers that may be elevated in biliary cancers are CA 19-9 and CEA. Not only for the final diagnosis but also for the classification of the tumor stage a whole range of diagnostic methods must be carried out. With sonography (ultrasound), abdominal organs are assessed non-invasively and without radiation exposure.

The extent of the tumor, the degree of bile duct narrowing and suspect or obviously affected lymph nodes in the abdomen are assessed. Since the method is easy to use and is not stressful for the patient, it can be repeated as often as required and can be used especially for follow-up and aftercare. Computed tomography (CT) produces tomographic images using X-rays and can provide information about the extent of the tumor, the spatial relationship to neighboring organs (infiltration), lymph node involvement and, in addition, distant metastases.

A CT scan of both the abdomen and the chest is often required to assess all metastatic pathways (liver and lung). Magnetic resonance imaging (MRI of the abdomen) provides similar results.

  • Sonography
  • Computer tomography

In this examination method, an endoscope with lateral view optics (duodenoscope) is advanced to the duodenum and the major duodenal papilla (papilla Vateri, father ́sche papilla) is probed.

This is the opening of the common duct of the liver, gallbladder (ductus coledochus) and pancreas (ductus pancreatica). If it is not possible to advance the instruments into the bile duct, it is necessary to carefully cut open the papilla opening to widen the opening. This procedure is called papillotomy or sphincterotomy.

In the second step of the examination, contrast medium is injected into these ducts against the flow direction of the digestive juices (retrograde). During the injection of the contrast medium, an X-ray of the upper abdomen is taken. The contrast medium thus makes narrowing of the ducts (stenoses), caused by gallstones or tumors, visible and thus assessable.

A carcinoma of the bile ducts impresses as a long-stretched narrowing (stenosis) of the bile ducts and extremely dilated (dilated) bile ducts in the liver before the tumor has narrowed. In addition, it is possible to take a tissue sample from the tumor (biopsy) using an endoscope and have the pathologist examine it histologically under the microscope, which can confirm the suspected diagnosis of a biliary carcinoma. During the ERCP, therapy can be performed in the same session.

For example, an inserted instrument can be used to remove a gallstone or, in the case of constrictions caused by tumors or inflammations, the bile flow can be restored by inserting a plastic or metal tube (stent).

  • Endoscopic retrograde cholangiopancreaticography (ERCP)

If the visualization of the bile ducts using ERCP is unsuccessful, there is the possibility of performing percutaneous transhepatic cholangiography. In this method, the liver is punctured with a hollow needle through the skin and a bile duct is located.

As in ERCP, a contrast medium is injected to show the bile ducts on an X-ray. It is also possible to use this method to drain the bile fluid to the outside via a so-called percutaneous transhepatic drainage (PTD) in order to eliminate a backlog in the bile ducts. Especially in the case of inoperable tumors, this can provide relief in cases of severe jaundice.

An overview x-ray of the thorax (chest x-ray) is taken to provide information about a metastatic infection of the lung. In endosonography, as in gastroscopy (esophago-gastro-duodenal endoscopy), a tube is first inserted into the duodenum in the immediate vicinity of the tumor. However, in this examination, an ultrasound probe is placed at the end of the tube instead of a camera.

With this method, the spread of the tumor in depth (infiltration) can be visualized by placing the ultrasound probe on the tumor and (regional) lymph nodes in the vicinity of the gallbladder can also be assessed. A related method is intraductal bile duct sonography, which can be used both during ERCP and PTC. For this purpose, a mini-probe is inserted directly into the affected bile duct and evaluated with ultrasound.

If the bile duct wall is tumorously affected, it appears thickened in the ultrasound and is characterized by loss of the characteristic stratification of the mucosal wall. This method can also be used to evaluate the infiltration of neighboring structures by the tumor. In advanced tumor stages, it is sometimes necessary to perform laparoscopy in order to correctly assess the regional extent, abdominal cavity involvement (peritoneal carcinosis) and liver metastases.

During this procedure, which is performed under general anesthesia, various instruments and a camera can be inserted through incisions in the abdominal skin, allowing the tumor spread to be observed. If necessary, a tissue sample (biopsy) can be taken to enable the pathologist to assess the tumor histologically under the microscope.

  • Percutaneous transhepatic cholangiography (PTC)
  • X-ray Thorax
  • Endosonography (endoluminal ultrasound)
  • Laparascopy