Lecture notes for medical students

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2. Introduction

3. Introduction
Cholangiocarcinoma : bile
duct cancers arising in the intra-
hepatic, peri-hilar, or distal
(extra-hepatic) biliary tree,
exclusive of gallbladder or
ampulla of Vater

4. Anatomic location

5. Anatomic location
Three anatomic regions:
•intrahepatic,
•extrahepatic (ie, perihilar),
• distal extrahepatic.

6. Klatskin tumor
Tumors involving the Right and
Left hepatic duct bifurcation are
referred to as Klatskin tumors
or hilar cholangiocarcinoma

7. Etiology

8. Etiology
• Idiopathic
• Congenital
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative

9. Etiology
• Primary sclerosing cholangitis
• Fibrocystic liver disease
• Parasitic infection
• Cholelithiasis and hepatolithiasis
• Lynch syndrome & biliary papillomatosis
• Viral Hepatitis
• Toxins- Printing press workers
• Diabetes
• Obesity
• HIV

10. Pathophysiology

11. Pathophysiology
•Arise from the epithelial
cells of the bile ducts
•Adenocarcinoma 95%
•SCC 5%

12. Clinical Features

13. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

14. Demography

15. Demography
• 3% of all GI malignany
• 60s and 70s of age
• male>female
• More in asians

16. Symptoms

17. Symptoms
• Cholangiocarcinomas
become symptomatic when
the tumor obstructs the
biliary drainage system,
causing painless jaundice

18. Symptoms
• Jaundice
• Clay-colored stools
• Bilirubinuria (dark urine)
• Pruritus
• Abdominal pain
• Weight loss
• Fever

19. Signs

20. Signs
–Jaundice
–Hepatomegaly
–Right upper quadrant mass

21. Signs
–Courvoisier Law.

22. Differential Diagnoses

23. Differential Diagnoses
• Bile Duct Strictures
• Bile Duct Tumors
• Biliary Disease
• Biliary Obstruction
• Cholangitis
• Cholecystitis
• Choledochal Cysts
• Gallstones (Cholelithiasis)

24. Prognosis

25. Prognosis
• Bad

26. Investigations

27. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histlogy

28. Laboratory Studies

29. Laboratory Studies
–T.bilirubin > 10mg%
–Elevated both toal and direct
bilirubin
–2- 10 fold increase ALP
–SGOT, SGPT – initially normal,
elevated in chronic biliary
obstruction
–Tumor markers-CA 19-9

30. Diagnostic Studies

31. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI- MRCP
• Endoscopy- ERCP, EUS , intraductal EUS
• PTC
• Nuclear scan- PET CT identifying occult
metastasis

32. Diagnostic Studies
Tissue Diagnosis
• Brush Cytology- ERCP
• FNAC- EUS
• CT/ USG guided FNAC

33. Operative Therapy

34. Operative Therapy
• Distal cholangiocarcinoma pancreatico-
duodenectomy Whipple procedure.
• Intra-hepatic cholangiocarcinoma hepatic
resection
– Peri-hilar cholangiocarcinoma - En bloc
resection of extra-hepatic bile ducts &
gallbladder + 5-10 mm bile duct margins
+ regional lymphadenectomy + Roux-en-
Y hepatico-jejunostomy
– Liver transplantation

35. Adjuvant Therapy

36. Adjuvant Therapy
• Limited role of Chemo and Radiotherapy

37. Palliative Therapy

38. Palliative Therapy
• Surgical biliary-enteric bypass
• Endoscopic/percutaneous
stenting
• Photodynamic therapy
• Radioembolization
• Chemotherapy
• Radiotherapy

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