Cholangiocarcinoma

Question 1

What is the most common site for bile duct cancers? What are these called? Where do they spread to?

Answer 1

Bifurcation of the right and left hepatic ducts (Klatskin tumours)
Invade locally and metastasise to local lymph nodes before spreading to peritoneal cavity, lung and liver

Question 2

What is the most common histological subtype of cholangiocarcinoma?

Answer 2

Adenocarcinoma arising from cholangiocytes within the biliary tree.

Question 3

What are the risk factors for cholangiocarcinoma?

Answer 3

Primary sclerosing cholangitis
UC
Infective 
Toxins
Congenital
Alcohol excess
Diabetes mellitus

Question 4

What are clinical features of cholangiocarcinoma?

Answer 4

Aymptomatic until late stage
Post-hepatic jaundice
Pruritus
Pale stools and dark urine
RUQ pain, early satiety, weight loss, anorexia, malaise

Question 5

What is Courcvoiser’s law?

Answer 5

In the presence of jaundice and an enlarged or palpable gallbladder, malignancy of the biliary tree or pancreas should be strongly suspected as cause is unlikely to be gallstones.
Sign may be present if obstructing tumour is distal to the cystic duct.

Question 6

What are ddx for post-hepatic jaundice?

Answer 6

Cholangiocaricnoma
Bile duct strictures
External compression from extra biliary tumour, benign biliary tumour, pancreatic tumour
Primary sclerosino cholangitis

Question 7

What investigations for cholangiocarinoma?

Answer 7

LFT for obstructive jaundice - raised bilirubin, raised ALP, raise GGT
Tumour markers CEA, CA19-9

Imaging:
USS
MRCP
ERCP for obtaining samples for cytology/histology
CT for staging

Question 8

What is surgical management for cholangiocarcinoma?

Answer 8

Complete surgical resection
Most patients are not suitable for surgery
Intrahepatic and Klatskin tumour resection requires a partial hepatectomy and reconstruction of the biliary tree.
Distal common bile duct tumours require pancreaticoduodenctomy (Whipple’s)

Question 9

What is palliative management of cholangiocarcinoma?

Answer 9

Stenting: ERCP may be used to stent the bile duct and relive obstructive symptoms
Surgery - surgical bypass procedures
Medical - palliative radiotherapy

Question 10

what are complications fo cholangiocarcinoma?

Answer 10

Biliary tract sepsis risk inreased

Biliary cirrhosis