The gall bladder
The gall bladder is a small pouch that stores and concentrates bile. Bile is a fluid made by the liver; its main function is to break down fats during digestion in the small bowel (small intestine). The gall bladder is connected to the small intestine and the liver by the bile ducts.
The gall bladder and the bile ducts are known as the biliary system.
Causes and risk factors
The cause of most gall bladder cancers is unknown. There are a number of risk factors that can increase your chances of developing this type of cancer. These are:
Gall stones and inflammation Gall bladder cancer is more likely to occur in people who have a history of gallstones, or in people who have inflammation of the gall bladder (cholecystitis). However, most people who have stones or an inflamed gall bladder won't develop gall bladder cancer.
Polyps Benign (non-cancerous) tumours, or polyps, of the gall bladder will increase the risk of developing gall bladder cancer.
Abnormal bile ducts Gall bladder cancer is slightly more common in people who are born with (congenital) abnormalities of the bile ducts.
Porcelain gall bladder People who have a condition called porcelain gall bladder, in which calcium forms in the wall of the gall bladder, also have a slightly increased risk of this type of cancer.
Smoking There is some evidence to suggest that people who smoke cigarettes are more likely to develop gall bladder cancer.
Family history People who have a close relative (parent, brother or sister) with gall bladder cancer are five times more likely to develop this type of cancer, although the risk is still very small.
Obesity Being very overweight can increase your risk of developing many cancers, including gall bladder cancer.
Signs and symptoms
Early gall bladder cancer often causes no symptoms. Early cancers are usually discovered unexpectedly when someone has surgery to remove gallstones. About 1 in 5 gall bladder cancers are found in this way.
Most gall bladder cancers are only discovered when they have reached quite a late stage. They can cause a variety of symptoms, including sickness and high temperatures, and sudden pain (which may come and go) in the upper right-hand side of the abdomen. The abdomen is the cavity containing several organs including the stomach, gall bladder and liver.
If the cancer blocks the bile duct it may stop the flow of bile from the gall bladder into the small bowel. This causes the bile to flow back into the blood and body tissues, and leads to the skin and whites of the eyes becoming yellow (known as jaundice). The urine also becomes a dark yellow colour and stools (bowel motions) are pale. The skin may become itchy. Mild discomfort in the abdomen, loss of appetite, high temperatures and weight loss may also occur.
Although these symptoms may be caused by other problems such as gallstones or infection of the gall bladder, it is important to get them checked by your doctor.
How it is diagnosed
Usually you begin by seeing your GP who will examine you. They will refer you to a hospital specialist for any tests that may be necessary and for expert advice and treatment. At the hospital, the doctor will ask you about your general health and any previous medical problems. They will then examine you and take blood samples to check your general health and that your liver is working properly. There are a number of commonly used tests to diagnose gall bladder cancer.
Ultrasound scan In this test, sound waves are used to make up a picture of the gall bladder and surrounding organs. It is done in the hospital scanning department. You will be asked not to eat, and to drink clear fluids only (nothing fizzy or milky) for 4–6 hours before the scan. Once you are lying comfortably on your back a gel is spread onto your abdomen. A small device like a microphone is then rubbed over the area. The sound waves are converted into a picture using a computer. The test is completely painless and takes 15–20 minutes.
CT (computerised tomography) scan A CT scan takes a series of x-rays which are fed into a computer to build up a detailed picture of your gall bladder and surrounding organs. On the day of the scan you will be asked not to eat or drink anything for at least four hours before your appointment. You will be given a special liquid to drink an hour before the test and again immediately before the scan. The liquid shows up on x-ray to ensure that a clear picture is obtained. For a few minutes this may make you feel hot all over. If you are allergic to iodine or have asthma, you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand.
Once you are comfortably positioned on your back on the couch, the scan can be taken. About half way through the scan a special dye will be injected into a vein to show up the blood vessels. This may make you feel warm or flushed for half an hour. The test itself is completely painless, but it will mean that you have to lie still for about 10–30 minutes. As you will have had little to drink before the scan, you will be advised to drink plenty afterwards to make up for this.
Spiral CT scan A spiral (or helical) CT scan is a new kind of CT. During a spiral CT, the x-ray machine rotates continuously around the body, following a spiral path to make cross-sectional pictures of the body.
MRI(magnetic resonance imaging) scan This test is similar to a CT scan, but uses magnetism instead of x-rays to build up cross-sectional pictures of your body. During the test you will be asked to lie very still on a couch inside a large metal cylinder which is open at both ends. The whole test may take up to an hour. It can be slightly uncomfortable and some people feel a bit claustrophobic during the scan. The scan is also very noisy, so you will be given earplugs or headphones to wear. A two-way intercom enables you to talk with the people controlling the scanner. If you have any metal implants (such as artificial hips or pacemakers) it will not be possible for you to have this test.
ERCP (endoscopic retrograde cholangio-pancreatography) This is a procedure by which an x-ray picture of the pancreatic duct and the bile duct can be taken. If necessary it can also be used to unblock the bile duct and insert a stent.
You will be asked not to eat or drink anything for about six hours before the test so that the stomach and first part of the small bowel (the duodenum) are both empty. You will be given a tablet or injection to make you relax (a sedative) and a local anaesthetic spray will be used to numb your throat. The doctor will then pass a thin flexible tube – known as an endoscope – through your mouth, into your stomach and the duodenum just beyond it.
Looking down the endoscope the doctor can find the opening where the bile duct and the duct of the pancreas drain into the duodenum. A dye which can be seen on x-ray can be injected into these ducts and the doctor will be able to see whether there are any abnormalities or blockages.
Angiogram As the bile duct is very close to the major blood vessels of the liver, an investigation called an angiogram may be done. The angiogram can check whether the blood vessels are affected by the tumour.
A fine tube is inserted into an artery in your groin and a dye is injected through the tube. The dye circulates in the arteries to make them show up on x-ray. An angiogram is carried out in a room within the x-ray department. Sometimes an MRI scan can be used to show up the blood vessels of the liver and then an angiogram will not be necessary.
Laparoscopy This is a small operation that allows the doctors to look at the gall bladder, the liver and other internal organs in the area around the gall bladder. It is done under a general anaesthetic and will mean a short stay in hospital.
While you are under anaesthetic the doctor will make a small cut (incision) in the front of your abdomen and insert a thin mini flexible tube containing a light and camera (laparoscope). The doctor is able to look at the gall bladder and can take a small sample of tissue (biopsy) for examination under a microscope.
During the operation, carbon dioxide gas is passed into the abdominal cavity. This can cause uncomfortable wind and/or shoulder pains for several days. The pain is often eased by walking about or taking sips of peppermint water. After the laparoscopy you will have one or two stitches in your abdomen.
Sometimes the gall bladder can be removed during a laparoscopy, as a treatment for gallstones or chronic inflammation of the gall bladder. This operation is called a laparoscopic cholecystectomy. If gall bladder cancer is found or suspected during this operation, the surgeon will change the operation to an open cholecystectomy (removal of the gall bladder through a larger cut in the abdomen). This makes it easier to remove all of the cancer.
Laparotomy If the doctor cannot make the diagnosis by the above tests, a procedure called a laparotomy may be done under a general anaesthetic. This involves making a cut (incision) into your abdomen so that the surgeon can examine the gall bladder, and the tissue around it, for cancer. If a cancer is found, but looks as though it has not spread to surrounding tissues, the surgeon may be able to remove the cancer or relieve blockages it may be causing.
The stage of a cancer describes its size and whether it has spread beyond its original site. Knowing the particular type and the stage of the cancer helps the doctors to decide on the most appropriate treatment.
Cancer can spread in the body, either in the bloodstream or through the lymphatic system. The lymphatic system is part of the body’s defence against infection and disease. The system is made up of a network of lymph glands or nodes that are linked by fine ducts containing lymph fluid. Doctors will usually look at the nearby lymph nodes to find the stage of the cancer.
There are four stages to cancer of the gall bladder.
- Stage 1 The cancer affects only the wall of the gall bladder. Approximately 1 in 4 cancers are at this stage when they are diagnosed.
- Stage 2 The cancer has spread through the full thickness of the wall of the gall bladder, but has not spread to nearby lymph nodes or adjacent organs.
- Stage 3 The cancer has spread to lymph nodes close to the gall bladder or has spread to the liver, stomach, colon or the small bowel.
- Stage 4 The cancer has spread very deeply into two or more organs close to the gall bladder or has spread to distant lymph nodes or organs such as the liver or lungs. This is known as metastatic or secondary cancer.
A different system called the TNM staging system is sometimes used, in which:
- T describes the size of the tumour.
- N describes whether the cancer has spread to the lymph nodes.
- M describes whether the cancer has spread to another part of the body, such as the liver (secondary or metastatic cancer).
Although this system is more complex, it can give more precise information about the tumour stage.
If the cancer comes back after initial treatment it is known as recurrent cancer.
Grading refers to the appearance of the cancer cells under the microscope and gives an idea of how quickly the cancer may develop. Low grade means that the cancer cells look very like normal cells; they are usually slow growing and they are less likely to spread. In high-grade tumours the cells look very abnormal, are likely to grow more quickly and are more likely to spread.
The type of treatment you are given will depend on a number of factors, including your general health, the position and size of the cancer in the gall bladder and whether the cancer has spread to other areas of the body.
Before you have any treatment, your doctor will give you full information about what it involves and explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent.
Benefits and disadvantages of treatment:
Treatment can be given for different reasons and the potential benefits will vary for each person. If you have been offered treatment that aims to cure your cancer, deciding whether to have the treatment may not be difficult. However, if a cure is not possible and the treatment is to control the cancer for a period of time, it may be more difficult to decide whether or not to go ahead.
If you feel that you can't make a decision about treatment when it is first explained to you, you can always ask for more time to decide.
You are free to choose not to have the treatment and the staff can explain what may happen if you do not have it. You don't have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.
surgeryis the main treatment for gall bladder cancer and may be used to remove all the cancer if it has not spread beyond the area of the gall bladder.
If the cancer has spread beyond the gall bladder, surgery may still be used to help improve a person’s symptoms by removing as much of the cancer as possible.
Whether surgery is possible or not depends on the results of the investigations described above. You may be referred to a surgeon with a special interest in this rare cancer.
Radiotherapy treats cancer by using high-energy x-rays that destroy the cancer cells, while doing as little harm as possible to normal cells. It is occasionally used for cancer of the gall bladder. It may either be given externally from a radiotherapy machine, or internally by placing radioactive material close to the tumour.
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy the cancer cells. They work by disrupting the growth of cancer cells. Chemotherapy has not been shown to be very effective for gall bladder cancer. However, it is thought that it may be helpful in controlling, for a while, gall bladder cancer that has spread elsewhere in the body.
If cancer in the gall bladder is causing a blockage in the bile duct, it may be possible for the doctor to insert a small tube (stent) during the ERCP. This can help to relieve any jaundice without the need for a surgical operation.
The stent is about 5–10cm long and as thick as a ball-point pen refill. The stent clears a passage through the bile duct to allow the bile to drain away. The preparation and procedure is the same as for ERCP described above. By looking at the x-ray image the doctor will be able to see the narrowing in the bile duct. The narrowing can be stretched using inflatable balloons (dilators) and the stent can be inserted through the endoscope to enable the bile to drain.
The stent usually needs to be replaced every 3–4 months to prevent it becoming blocked. If it does block, jaundice and/or high temperatures will occur. It is important to tell your specialist about these symptoms as early as possible. Antibiotic treatment may be needed and your specialist may advise that the stent be exchanged for a new one. For most people this procedure can be done relatively easily.
Research into treatments for gall bladder cancer is ongoing and advances are being made. Cancer doctors use clinical trials to assess new treatments.
You may be asked to take part in a clinical trial. Your doctor must discuss the treatment with you, so that you have a full understanding of the trial and what it means to take part. You may decide not to take part or to withdraw from a trial at any stage. You will then receive the best standard treatment available.
During your diagnosis and treatment you are likely to experience a number of different emotions, from shock and disbelief to fear and anger. At times these emotions can be overwhelming and hard to control. It is quite natural, and important, to be able to express them.
Everyone has their own ways of coping with difficult situations; some people find it helpful to talk to friends or family, while others prefer to seek help from people outside their situation. Others prefer to keep their feelings to themselves. There is no right or wrong way to cope, but help is available if you need it.