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Detailed Guide: Bile Duct Cancer
How Is Bile Duct Cancer Diagnosed?
Signs and Symptoms of Bile Duct Cancer

The most common symptom of bile duct cancer is jaundice. Jaundice occurs when the liver cannot get rid of bile, and one of the chemicals in bile called bilirubin "backs up" into the bloodstream. Bilirubin is greenish yellow and colors all the body tissues, including the skin and the white part of the eyes, making people with this condition begin to look yellow. Because bilirubin also contributes to the brown coloring of bowel movements, the blockage of its flow into the intestine might lighten the color of one's stool. Bilirubin will also come out in the urine and turn it dark.

Bile and bilirubin also cause itching. Jaundice is almost always due to hepatitis or to blockage of the bile duct. It is important to realize that most causes of bile duct blockage are not caused by cancer. Most often a stone in the bile duct that escaped from the gallbladder (gallstone) causes the jaundice. Whenever jaundice occurs, a doctor should be seen immediately.

Other signs and symptoms of bile duct cancer include weight loss, loss of appetite, and fever. Early bile duct cancers usually do not cause pain. Usually the main symptoms from intrahepatic bile duct cancer are weight loss and fatigue. Jaundice occurs later. As the cancer spreads, pain may develop in the stomach area.

If there is reason to suspect that you have bile duct cancer, your doctor will perform certain exams and order tests to make a diagnosis. If these tests indicate you do have bile duct cancer, additional tests will be done to determine the stage of the cancer (how far the disease has spread).

History and physical exam: When your doctor "takes a history," he or she will ask you a series of questions about your symptoms and risk factors. A physical exam for patients suspected of having bile duct cancer will include a careful exam of the abdomen to feel for masses or enlarged organs, and a general survey of the rest of the body.

Blood chemistry and tumor markers: Tests of the blood called blood chemistry tests can very accurately determine if there is blockage of the bile duct. In addition to a high level of bilirubin, the tests will find elevated levels of another substance, called alkaline phosphatase, which is released by damaged bile duct cells. Although elevations of these substances indicate bile duct obstruction, they cannot show if it is due to cancer or some other reason.

Tumor markers are substances produced by cancers and found in the blood. The presence of these in high amounts usually means that there is cancer, but the absence of these markers does not mean there is no cancer, since not all cancers produce these markers. People with bile duct cancer may have blood elevations of 2 markers -- carcinoembryonic antigen (CEA) and CA 19-9. For more information on these substances, please see the American Cancer Society document, Tumor Markers.

Imaging Tests

Imaging techniques can often identify a bile duct blockage and the blockage location. But they often do not reveal whether the blockage is due to a tumor or a benign problem such as scarring.

Ultrasonography (ultrasound): Ultrasound uses sound waves to produce images of internal organs. A transducer emits sound waves and detects the echoes as they bounce off the organs. The pattern of echoes is processed by a computer to produce images. The echoes produced by most tumors differ from those of normal tissue. These patterns of echoes can help distinguish some types of benign and malignant tumors from one another. Newer techniques, known as endoscopic or laparoscopic ultrasound, combine ultrasound with the use of a thin, lighted tube with an attached viewing device (an endoscope or laparoscope). The endoscope is inserted through the mouth and passed through the stomach and near the bile duct area. The laparoscope is inserted through a surgical incision (cut) in the side of the patient's body. Both procedures allow the doctor to place the ultrasound transducer near the bile duct to produce more detailed images than a standard ultrasound. If there is a tumor, the doctor may be able to tell if and how far it has invaded, which helps in planning for surgery. Ultrasound can often tell whether the cancer has invaded the liver. The ultrasound may also be used to spot a tumor to biopsy.

Computed tomography (CT): The CT scan is an x-ray procedure that produces detailed cross-sectional images of your body. Instead of taking one picture, like a conventional x-ray, a CT scanner takes many pictures as it rotates around you. A computer then combines these pictures into an image of a slice of your body. The machine will take multiple pictures of the part of your body that is being studied.

CT scans are often used to make the initial diagnosis of bile duct cancer and are helpful in determining the stage of the cancer (determining the extent of its spread).

CT scans can also show the organs near the bile duct, as well as lymph nodes and distant organs where the cancer may spread or metastasize. The CT scan can help to determine whether surgery is a good treatment option.

This test can help tell whether your cancer has spread into your liver or other organs. Often, after the first set of pictures is taken, you will receive an intravenous (IV) injection of a "dye," or contrasting agent that helps better outline structures in your body. A second set of pictures is then taken.

CT scans can also be used to guide a biopsy needle precisely into a suspected metastasis. For this procedure, called a CT-guided needle biopsy, you remain on the CT scanning table, while a radiologist advances a biopsy needle toward the location of the mass. CT scans are repeated until the doctors are confident that the needle is within the mass. A fine-needle biopsy sample (tiny fragment of tissue) or a core-needle biopsy sample (a thin cylinder of tissue about ½-inch long and less than 1/8-inch in diameter) is removed and examined under a microscope.

CT scans are more tedious than regular x-rays because they take longer and you need to lie still on a table while they are being done. But just like other computerized devices, they are getting faster and your stay might be pleasantly short. Also, you might feel a bit confined by the ring you lie within when the pictures are being taken.  

You will also need an IV line through which the contrast "dye" is injected. The injection can also 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. Please be sure to tell the doctor if you have ever had a reaction to any contrast material used for x-rays. You may be asked to drink 1 to 2 pints of a solution of contrast material. This helps outline the intestine to allow for more accurate imaging of any tumor.

Magnetic resonance imaging (MRI): MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. Not only does this produce cross-sectional slices of the body like a CT scanner, but it can also produce slices that are parallel with the length of your body. A contrast material might be injected just as with CT scans, but is used less often. Some doctors believe that MRI is the best way to look for bile duct cancer. This is particularly true of a new method called MRI cholangiopancreatography. This technique can often outline the exact site of bile duct blockage.

MRI scans are a little more involved than CT scans. First, they take longer -- often up to an hour. Also, you have to be placed inside a large tube, which is confining and can upset some people with claustrophobia (an anxiety disorder that involves fear of enclosed or confined spaces). The machine also makes a thumping noise, but many places will provide headphones with music to block this out.

Endoscopic retrograde cholangiopancreatography (ERCP): In this procedure, a doctor passes a long, flexible tube down the patient's throat, through the esophagus and stomach, and into the common bile duct. The patient is usually sedated so that the procedure is not uncomfortable. A small amount of contrast medium (harmless dye) helps outline the bile duct and pancreatic duct in x-ray images. The images can show narrowing or blockage of the bile duct or pancreatic duct and the doctor can also use the instrument to take cell samples. Sometimes doctors can find cancer cells in the fluid in the duct.


Cholangioscopy: This is a relatively new procedure that uses a very thin fiberoptic tube. The tube can be passed into the bile duct through the mouth after routine ERCP. It also can be passed through a needle placed into a liver bile duct through the abdominal wall. From there it can be maneuvered into the bile duct. This allows doctors to see any tumors and even biopsy them.


Positron emission tomography (PET): A PET scan uses glucose (a form of sugar) that contains a radioactive atom. The substance emits tiny subatomic particles called positrons. A special camera records the precise location of the positrons as they leave the body. Cells of the body absorb varying amounts of the radioactive sugar, depending on their rate of metabolism. Unlike most other imaging tests, which provide views of the shape and size of internal structures only, PET scanning also provides information about their metabolic activity. Since the metabolism of cancer cells differs from that of normal cells, PET scanning can often tell if a bile duct obstruction is caused by a cancer. It is also useful in determining how far the cancer may have spread.

Cholangiography: In this test, contrast dye is injected into the bile duct and x-ray pictures are taken. A radiologist can inject the dye through a needle that has been placed in a dilated (opened) bile duct in the liver. This is usually done with ultrasound guidance. A cholangiogram is a very important test in diagnosing bile duct cancer because it can find the exact site of the cancer and show how close it is to the liver. This helps doctors decide if the cancer can be treated with surgery and how extensive the surgery will need to be. If a cholangiogram cannot be done, an ERCP procedure can be performed by a gastroenterologist (medical doctor specializing in intestinal diseases).

Angiography: For this test, a cannula (small tube) is inserted into a blood vessel and maneuvered until it reaches the area to be studied. Contrast dye is injected rapidly and a series of x-ray images is then taken. When the pictures are complete, the cannula is removed. Angiography is occasionally used to show surgeons the location of blood vessels next to bile duct cancer, so that the operation can be planned to minimize blood loss. Sometimes, if there are too many blood vessels, the surgeons cannot remove the cancer and surgery will not be done.

Other Tests

Laparoscopy: This procedure uses a thin, lighted tube through which a doctor can view the bile duct, gallbladder, the liver, and other internal organs, and tissue in the area around the bile duct. The tube is inserted through a small incision (cut) in the front of the abdomen. Laparoscopy provides a view of organs that can help in planning surgery or other treatments, and can help doctors confirm the stage (how far the tumor has spread) of the cancer. Also, doctors can manipulate small instruments through the laparoscopic incision(s) to remove small tissue samples to examine under the microscope.

Biopsy: Although imaging tests can suggest that a bile duct cancer is likely to be present, a sample of bile duct cells or tissue must be examined under a microscope to be sure of that diagnosis. CT scans can be used to guide a biopsy needle precisely into a suspected tumor. For this procedure, a CT-guided needle biopsy (described above) is done. Some tissue is removed and examined under a microscope. This can also be done with cholangioscopy.

Bile duct cells and tiny fragments of bile duct tissue can also be sampled by biliary brushing. For this procedure, an endoscope is guided from the mouth to the bile duct, as described earlier in the section on cholangiography. Instead of injecting contrast dye and taking x-ray pictures (as for ERCP), the doctor advances a small brush with a very long, flexible handle through the endoscope. The end of the brush (which resembles a tiny bottlebrush) is used to scrape cells and small tissue fragments from the lining of the bile duct. As with a needle biopsy, the cells and tissues are checked under a microscope for signs of cancer. Last Revised: 04/17/2006

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