By Dr Ananya Mandal, MD
Those with a gallbladder disease usually manifest with abdominal pain, discomfort, bloating, nausea, vomiting and jaundice. These symptoms may be features of other ailments as well and are common with liver disease.
A detailed evaluation is needed to rule out liver disease and other gallbladder pathologies like gallstones and gall bladder inflammation or cholecystitis.
In most cases gall bladder cancer in early stages is a chance finding while operating for gallstones or gall bladder inflammation or other routine examination. The symptoms manifest only in later stages.
Diagnosis and treatment is more often than not made by a gastroenterologist, who is an expert in diseases of the digestive system.
Diagnosis of gall bladder cancer involves medical history assessment, physical examination and so forth.
Medical history assessment
History of gallstones, cholescystitis and earlier gall bladder disease like Primary sclerosing cholangitis are important. Family history of gall bladder disease is also important in assessing the risk of gallbladder cancer.
After medical history assessment physical examination is performed. The abdomen is felt and the enlarged gall bladder may sometimes be felt at the right upper part of the abdomen.
The lymph nodes, if affected may also be swollen and may be palpated. General examination includes examination for jaundice with yellowing of skin, nail beds and eyes.
Blood tests may be recommended. Normally liver function tests are suggested. These include bilirubin levels and levels of various enzymes that are produced in the liver like AST (Aspartate transaminase) and ALT (Alanine transaminase).
This series of tests shows if the liver and gallbladder are working normally. Normally low amounts of these enzymes and bilirubin is present in blood their abnormal rise usually means abnormalities of the biliary system, gall bladder or liver.
Ultrasound scan of the abdomen
An ultrasound scan of the abdomen is usually prescribed next. This uses ultrasound waves to look at the various organs of the body.
This is a painless test that involves the use of a probe that emits the sound waves over the abdomen. The waves hit an organ within the abdomen and are picked up by the probe. This is then transmitted as an image onto a monitor.
Ultrasound can pick up about 1 in 2 gallbladder cancers. Tumors of the gall bladder and some liver pathology may also be detected.
Imaging studies like a CT scan of the abdomen. A Computerized tomography scan uses highly developed X-rays to show the organs within the body. A CT scan abdomen is helpful in detection of the gall bladder cancer and also sees if the cancer has spread to other organs.
Other tests for gallbladder cancer
ERCP stands for endoscopic retrograde cholangiopancreatography and MRCP stands for magnetic resonance cholangiopancreatography.
For ERCP the patient is sedated and a long, thin flexible tube is inserted into the mouth and passed into the duodenum. The tube has a small light and a camera at its tip. The tube explores and looks at the insides of the biliary tract and checks for narrowing and blockage. The whole test takes anything from 30 minutes to 2 hours.
MRCP is a type of MRI scan that shows the picture of the pancreas, gallbladder and bile ducts.
Biopsy of the gallbladder
A biopsy or fine needle aspiration of the gallbladder. A biopsy involves removing a sample of tissue from the affected organ and examining it under the microscope. This is the most certain way of detecting the cancer also staging the cancer to see how advanced the cancer is.
A biopsy may be performed after a surgery that involves taking out whole of the gall bladder. A biopsy may also be taken during an ERCP procedure or with a fine needle aspiration (FNAC).
The FNAC may be performed with the help of an ultrasound scan or CT scan. A very thin needle is inserted into the gall bladder and a sample of fluid and tissue is taken and examined under the microscope.
Other tests include an MRI scan, Endoscopic ultrasound, Cholangiography, and an open operation to look at the gall bladder (Laparoscopy or laparotomy). An angiogram may be prescribed. It looks at the blood vessels around the biliary system.
Staging gallbladder cancer
The stage of a cancer describes its size and whether it has spread beyond its original site. Knowing the stage of the cancer helps to determine the most appropriate treatment and helps to predict the possible outcome of therapy.
Four stages of gallbladder cancer
There are four stages of cancer of the gall bladder:
Stage 1 – At this stage only the wall of the gall bladder is affected. Approximately a quarter of gall bladder cancers are at this stage when they are diagnosed.
Stage 2 – The cancer in this stage spreads to the full thickness of the wall of the gall bladder but has not spread to the nearby lymph nodes or surrounding organs.
Stage 3 – In this stage the cancer spreads to the lymph nodes close to the gall bladder or has spread to the liver, stomach, colon or the small bowel.
TNM staging system
A different system called the TNM staging system is sometimes used. In this the T describes the size of the tumour, N describes whether the cancer has spread to the lymph nodes and M describes whether the cancer has spread to another part of the body.
In addition, the tumor is also graded. Grading gives an idea of how quickly a cancer may develop. A low grade cancer usually is slow growing and a high grade tumor usually means a more quickly growing and spreading tumor.
Reviewed by April Cashin-Garbutt, BA Hons (Cantab)