Cholangiocarcinoma

Question 1

What are Cholangiocarcinomas?

Answer 1

Cancer of the bilary system - predominantly arisies in the extraheaptic biliary system. Most common site is at the bifuraction of the right and left hepatic ducts (klatdkin tumours). Typically slow growing that invade locally and matatases to local lymph nodes before spreaing distally to peritoneal cavity, lungs and liver.

Majority adenocarcinoma and some SCC.

Question 2

What are the risk factors for Cholangiocarcinomas?

Answer 2

Primary scleroising cholangitis
UC
Infective - liver flukes, HIV, hepatitis
Toxins - chemicals in rubber and aircraft industry
Congenital - carolis disease, choledochal cyst
Alcohol excess
DM

Question 3

What are the clinical features of Cholangiocarcinomas?

Answer 3

Aymptomatic until late stage

But symptoms can include post-heatic jaundice and pruritus with pale stools and dark urine. Less commonly - RUQ pain, early saiety, weght oss, anorexia and malasise

Examintion jaundice and cachexia

Question 4

What is courvoisiers law?

Answer 4

Presence of jaundice nad enlarged or palpable galbaldder, malignancy or biliary tree or pancreas should be strongly suspected.

Question 5

What are the differential diagnosis for Cholangiocarcinomas?

Answer 5

Causes of post-hepatic jaundice:
Obstrctive choledocholithiasis 
Bile duct strictures 
Choledochal cysts 
External compression of extre-biliary tumour 
Tumors 
Primary biliary cirrhosis
PSC

Question 6

What investigations should be ordered in supected Cholangiocarcinomas?

Answer 6

Bloods - GGT
Tumour markers - CEA, CA19-9

Imaging -
ultrasound
MRCP - GOLD standard
ERCP - obtain samples for cytology/histology
CT -staging, also can use angiogram for pre-op planning

Question 7

What is the mangement for Cholangiocarcinomas?

Answer 7

Complete surgical resection - definitive cure but majority inoperable disease

Intraheptic or klatskin tumours - partial hepatectomy and reconstruction of the bilary tree
Distal common duct tumours - pancreaticoduodenectomy (Whipples procedure)

Radiotherapy- adjuvant and neoadjuvant

Question 8

What is the palliative managment of Cholangiocarcinomas?

Answer 8

Stenting - ERCP to place stent to relive symptoms
Surgery - surgical bypass if cant be relived by stenting
Medical - pallaitive radiothearpy/ chemotheapry

Question 9

What are the complications of Cholangiocarcinomas?

Answer 9

Biliary tract sepsis

Secondary biliary cirrhosis