Bile Duct (Cholangiocarcinoma) Cancer

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Early Detection, Diagnosis, and Staging TOPICS

How is bile duct cancer diagnosed?

Most bile duct cancers are not found until patients go to a doctor because they have symptoms. The doctor will need to take a history and do a physical exam, and then might order some tests.

History and physical exam

If there is reason to suspect that you might have bile duct cancer, your doctor will want to take a complete medical history to check for risk factors and to learn more about your symptoms.

A physical exam is done to look for signs of bile duct cancer or other health problems. If bile duct cancer is suspected, the exam will focus mostly on the abdomen to check for any lumps, tenderness, or buildup of fluid. The skin and the white part of the eyes will be checked for jaundice (a yellowish color).

If symptoms and/or the results of the physical exam suggest you might have bile duct cancer, other tests will be done. These could include lab tests, imaging tests, and other procedures.

Blood tests

Tests of liver and gallbladder function

The doctor may order lab tests to find out how much bilirubin is in the blood. Bilirubin is the chemical that causes jaundice. Problems in the bile ducts, gallbladder, or liver can raise the blood level of bilirubin. A high bilirubin level tells the doctor that there may be problems with the bile duct, gallbladder, or liver.

Along with tests for bilirubin, the doctor may also order tests for albumin, for liver enzymes (alkaline phosphatase, AST, ALT, and GGT), and certain other substances in your blood. These are sometimes called liver function tests. They can indicate bile duct, gallbladder, or liver disease. If levels of these substances are higher, it might point to blockage of the bile duct, but they can’t show if it is due to cancer or some other reason.

Tumor markers

Tumor markers are substances made by cancer cells that can sometimes be found in the blood. People with bile duct cancer may have high blood levels of the CEA and CA 19-9 tumor markers. High amounts of these substances often mean that cancer is present, but the high levels can also be caused by other types of cancer, or even by problems other than cancer. Also, not all bile duct cancers make these tumor markers, so low or normal levels do not always mean cancer is not present.

These tests can sometimes be useful after a person is diagnosed with bile duct cancer. If the levels of these markers are found to be high, they can be followed over time to help tell how well treatment is working.

Imaging tests

Imaging tests use x-rays, magnetic fields, or sound waves to create pictures of the inside of your body. Imaging tests can be done for a number of reasons, including:

  • To help find suspicious areas that might be cancer
  • To help a doctor guide a biopsy needle into a suspicious area to take a sample
  • To learn how far cancer has spread
  • To help find out if treatment is working
  • To look for signs of the cancer coming back after treatment

Imaging tests can often show a bile duct blockage. But they often can’t show if the blockage is caused by a tumor or a benign problem such as scarring.

People who have (or might have) bile duct cancer may have one or more of the following tests.

Ultrasound

For this test, a small, microphone-like instrument called a transducer gives off sound waves and picks up their echoes as they bounce off organs inside the body. The echoes are converted by a computer into an image on a screen. The echo patterns can help find tumors and show how far they have grown into nearby areas. They can also help tell whether some tumors are benign or malignant.

Abdominal ultrasound: This is often the first imaging test done in people who have symptoms such as jaundice or pain in the right upper part of their abdomen.

This is an easy test to have and does not use radiation. You simply lie on a table while the doctor or ultrasound technician moves the transducer along the skin over the right upper part of the abdomen. Usually, the skin is first lubricated with gel.

This type of ultrasound can also be used to guide a needle into a suspicious area or lymph node so that cells can be removed (biopsied) and looked at under a microscope. This is known as an ultrasound-guided needle biopsy.

Endoscopic or laparoscopic ultrasound: In these techniques, the doctor puts the ultrasound transducer inside the body and closer to the bile duct, which gives more detailed images than a standard ultrasound. The transducer is on the end of a thin, lighted tube that has an attached viewing device. The tube is either passed through the mouth, down through the stomach, and into the small intestine near the bile ducts (endoscopic ultrasound) or through a small surgical cut in the side of the patient’s body (laparoscopic ultrasound).

If there is a tumor, the doctor might be able to see how far it has grown and spread, which can help in planning for surgery. Ultrasound may be able to show if nearby lymph nodes are enlarged, which can be a sign that cancer has reached them. Needle biopsies of suspicious areas might be taken as well.

Computed tomography (CT) scan

The CT scan uses x-rays to make detailed cross-sectional images of your body. Instead of taking one x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these into images of slices of the part of your body that is being studied.

A CT scanner has been described as a large donut, with a narrow table that slides in and out of the middle opening. You will need to lie still on the table while the scan is being done. CT scans take longer than regular x-rays, and you might feel a bit confined by the ring while the pictures are being taken.

Before any pictures are taken, you might be asked to drink 1 to 2 pints of a liquid called oral contrast. This helps outline the intestine so that certain areas are not mistaken for tumors. You might also need an IV (intravenous) line through which a different kind of contrast dye (IV contrast) is injected. This helps better outline structures in your body.

The injection can cause some flushing (redness and warm feeling). Some people are allergic and get hives or, rarely, more serious reactions like trouble breathing and low blood pressure. Be sure to tell the doctor if you have any allergies or have ever had a reaction to any contrast material used for x-rays.

CT scans can have several uses:

  • They often help diagnose bile duct cancer by showing tumors in the area.
  • They can help stage the cancer (find out how far it has spread). CT scans can show the organs near the bile duct (especially the liver), as well as lymph nodes and distant organs where cancer might have spread to.
  • A type of CT known as CT angiography can be used to look at the blood vessels around the bile ducts. This can help determine if surgery is a treatment option.
  • CT scans can also be used to guide a biopsy needle into a suspected tumor or metastasis. For this procedure, called a CT-guided needle biopsy, the patient remains on the CT scanning table, while the doctor advances a biopsy needle through the skin and toward the mass. CT scans are repeated until the needle is within the mass. A biopsy sample is then removed and looked at under a microscope.

Magnetic resonance imaging (MRI) scan

Like CT scans, MRI scans provide detailed images of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of x-rays. A contrast material called gadolinium may be injected into a vein before the scan to better see details.

MRI scans provide a great deal of detail and can be very helpful in looking at the bile ducts and nearby organs. Sometimes they can help tell a benign tumor from a cancerous one.

Special types of MRI scans may also be used in people who may have bile duct cancer:

  • MR cholangiopancreatography (MRCP) can be used to look at the bile ducts and is described in the section on cholangiography.
  • MR angiography (MRA) looks at blood vessels and is mentioned in the section on angiography.

MRI scans can be a little more uncomfortable than CT scans. They take longer, often up to an hour. You may have to lie inside a narrow tube, which is confining and can upset people with a fear of enclosed spaces. Special, more open MRI machines can sometimes be used instead. The MRI machine makes buzzing and clicking noises that you may find disturbing. Some places will provide earplugs to help block this noise out.

Cholangiography

A cholangiogram is an imaging test that looks at the bile ducts to see if they are blocked, narrowed, or dilated (widened). This can help show if someone might have a tumor that is blocking a duct. It can also be used to help plan surgery. There are several types of cholangiograms, which have different pros and cons.

Magnetic resonance cholangiopancreatography (MRCP): This is a non-invasive way to image the bile ducts using the same type of machine used for standard MRI scans. It does not require an endoscope or an IV infusion of a contrast agent, unlike the other types of cholangiograms. Because it is non-invasive, doctors often use MRCP if the purpose of the test is just to image the bile ducts. But this test can’t be used to get biopsy samples of tumors or to place stents (small tubes) in the ducts to keep them open.

Endoscopic retrograde cholangiopancreatography (ERCP): In this procedure, a doctor passes a long, flexible tube (endoscope) down the throat, through the esophagus and stomach, and into the first part of the small intestine. This is usually done while you are sedated (given medicine to make you sleepy). A small catheter (tube) is passed from the end of the endoscope and into the common bile duct. A small amount of contrast dye is injected through the tube to help outline the bile ducts and pancreatic duct as x-rays are taken. The images can show narrowing or blockage of these ducts.

This test is more invasive than MRCP, but it has the advantage of allowing the doctor to take samples of cells or fluid to be looked at under a microscope. ERCP can also be used to place a stent (a small tube) into a duct to help keep it open.

Percutaneous transhepatic cholangiography (PTC): In this procedure, the doctor places a thin, hollow needle through the skin of the belly and into a bile duct within the liver. You will get medicine through an IV line to make you sleepy before the test. A local anesthetic is also used to numb the area before inserting the needle. A contrast dye is then injected through the needle, and x-rays are taken as it passes through the bile ducts. Like ERCP, this approach can also be used to take samples of fluid or tissues or to place stents (small tubes) in the bile duct to help keep it open. Because it is more invasive (and might cause more pain), PTC is not usually used unless ERCP has already been tried or can’t be done for some reason.

Angiography

Angiography is an x-ray procedure for looking at blood vessels. For this test, a small amount of contrast dye is injected into an artery to outline blood vessels before x-ray images are taken. The images show if blood flow in an area is blocked or affected by a tumor, and any abnormal blood vessels in the area. The test can also show if a bile duct cancer has grown through the walls of certain blood vessels. This information is mainly used to help surgeons decide whether a cancer can be removed and to help plan the operation.

X-ray angiography can be uncomfortable because the doctor has to put a small catheter (a flexible hollow tube) into the artery leading to the bile ducts to inject the dye. Usually the catheter is put into an artery in your inner thigh and threaded up into the artery supplying the bile ducts. A local anesthetic is often used to numb the area before inserting the catheter. Then the dye is injected quickly to outline all the vessels while the x-rays are being taken.

Angiography can also be done with a CT scanner (CT angiography) or an MRI scanner (MR angiography). These techniques are now used more often because they give information about the blood vessels without the need for a catheter. You may still need an IV line so that a contrast dye can be injected into the bloodstream during the imaging.

Other tests

Doctors may also place special instruments (endoscopes) into the body to get a more direct look at the bile duct and surrounding areas. The scopes may be passed through small surgical incisions or through natural body openings like the mouth.

Laparoscopy

Laparoscopy is a type of minor surgery. The doctor inserts a thin tube with a light and a small video camera on the end (a laparoscope) through a small cut in the front of the abdomen to look at the bile duct, gallbladder, liver, and other organs and tissues in the area. (Sometimes more than one cut is made.) This procedure is typically done in the operating room while you are under general anesthesia (in a deep sleep).

Laparoscopy can help doctors plan surgery or other treatments, and can help assess the stage (extent) of the cancer. If needed, doctors can also insert instruments through the incisions to remove small biopsy samples to be looked at under a microscope. This procedure is often done before surgery to remove the cancer, to help make sure the tumor can be removed completely.

Cholangioscopy

This procedure can be done during an ERCP (see above). The doctor passes a very thin fiber-optic tube with a tiny camera on the end down through the larger tube used for the ERCP. From there it can be maneuvered into the bile ducts. This lets the doctor see any blockages, stones, or tumors and even biopsy them.

Biopsy

Imaging tests (ultrasound, CT or MRI scans, cholangiography, etc.) might suggest that a bile duct cancer is present, but in many cases a sample of bile duct cells or tissue is removed (biopsied) and looked at under a microscope to be sure of the diagnosis.

But a biopsy may not always be done before surgery for a possible bile duct cancer. If imaging tests suggest there is a tumor in the bile duct, the doctor may decide to proceed directly to surgery and to treat it as a bile duct cancer (see the section “Surgery for bile duct cancer”).

Types of biopsies

There are several ways to take biopsy samples to diagnose bile duct cancer.

During cholangiography: If ERCP or PTC is being done, a sample of bile may be collected during the procedure to look for tumor cells within the fluid.

Bile duct cells and tiny fragments of bile duct tissue can also be sampled by biliary brushing. Instead of injecting contrast dye and taking x-ray pictures (as for ERCP or PTC), the doctor advances a small brush with a long, flexible handle through the endoscope or needle. The end of the brush is used to scrape cells and small tissue fragments from the lining of the bile duct, which are then looked at under a microscope.

During cholangioscopy: Biopsy specimens can also be taken during cholangioscopy. This lets the doctor see the inside surface of the bile duct and take samples of suspicious areas.

Needle biopsy: For this test, a thin, hollow needle is inserted through the skin and into the tumor without first making a surgical incision. (The skin is numbed first with a local anesthetic.) The needle is usually guided into place using ultrasound or CT scans. When the images show that the needle is in the tumor, a sample is drawn into the needle and sent to the lab to be viewed under a microscope.

In most cases, this is done as a fine needle aspiration (FNA) biopsy, which uses a very thin needle attached to a syringe to suck out (aspirate) a sample of cells. Sometimes, the FNA doesn’t provide enough cells for a definite diagnosis, so a core needle biopsy may be done, which uses a slightly larger needle to get a bigger sample.

For more information about biopsies and how they are tested, see our document Testing Biopsy and Cytology Specimens for Cancer.


Last Medical Review: 11/01/2014
Last Revised: 11/01/2014