Diagnosis of biliary tract cancers

Diagnosis is the process of finding out the cause of a health problem. Diagnosing biliary tract cancers often means first ruling out other health conditions that share similar symptoms. It can be a very worrying time for you and your loved ones. Sometimes this process is quick. Sometimes it can feel long and frustrating. But it's important for doctors to get all the information they need before making a diagnosis of cancer.

Diagnosing biliary tract cancers usually begins with a visit to your family doctor. Your doctor will ask you about any symptoms you have and do a physical exam. Based on this information, your doctor may refer you to a specialist or order tests to check for gallbladder cancer, bile duct cancer or other health problems. Biliary tract cancers can start in cells of either the gallbladder or bile duct. When cancer starts in gallbladder cells, it is called primary gallbladder cancer. When cancer starts in bile duct cells, it is called primary bile duct cancer.

The following tests are usually used to rule out or diagnose biliary tract cancers. Many of the tests that are used to diagnose cancer are also used to find out the stage (how far the cancer has spread). Your doctor may also order other tests to check your general health and to help plan your treatment.

Biliary tract cancers are most often diagnosed at an advanced stage because they typically don't cause symptoms earlier. Sometimes, a biliary tract cancer may be found earlier when the gallbladder is removed due to problems such as gallstones or chronic cholecystitis (long-term inflammation of the gallbladder).

Your health history is a record of your symptoms, risks and all the medical events and problems you have had in the past. Your doctor will ask questions about your history of:

• symptoms that suggest a biliary tract cancer
• gallstones
• gallbladder polyps
• porcelain gallbladder
• chronic inflammation of the biliary tract (such as cholecystitis or primary sclerosing cholangitis)
• bile duct adenomas or hamartomas
• thorium dioxide (Thorotrast) exposure

Your doctor may also ask about your family history of:

• gallbladder or bile duct cancer
• risks for biliary tract cancers( for example, gallbladder polyps or primary sclerosing cholangitis)
• other cancers

A physical exam allows your doctor to look for any signs of gallbladder or bile duct cancer. During a physical exam, your doctor may:

• feel the abdomen for any lumps, tenderness, swelling or fluid
• look at the whites of the eyes and skin for yellowing (a sign of jaundice)
• feel the lymph nodes in the groin

Find out more about physical exam.

Blood chemistry tests measure certain chemicals in the blood. They show how well certain organs are working and help find problems. Blood chemistry tests that can help diagnose a biliary tract cancer include the following.

Liver function tests (also called a liver panel) are a group of blood chemistry tests that are often ordered together. These tests can tell the healthcare team that there may be a problem with the liver and biliary tract caused by a biliary tract cancer.

Albumin is a protein made by the liver. Low levels of albumin may be a sign that the liver is damaged or not working normally.

Alkaline phosphatase (ALP) is an enzyme found in the liver and other tissues in the body. A high level of ALP in the blood may be a sign that the liver is not working normally.

Aspartate aminotransferase (AST) is an enzyme found in liver and heart cells. When liver or heart cells are damaged, they release AST into the blood. A high level of AST may be a sign of a problem with the liver.

Alanine aminotransferase (ALT) is an enzyme found in the liver and kidneys. A high level of ALT in the blood may signal the liver is not working normally.

Bilirubin( a chemical in bile) is made when old red blood cells (RBCs) break down. High levels of bilirubin may signal a problem with the liver or gallbladder or a blockage in the bile ducts.

Gamma-glutamyl transferase (GGT) is an enzyme found in the liver, bile ducts, and other tissues in the body. When liver or bile duct cells are damaged, they release GGT into the blood. High levels of GGT may be a sign of a problem with the liver or biliary tract.

Find out more about blood chemistry tests, including liver function tests.

Tumour markers are substances found in the blood, in tissue or in bodily fluids. An abnormal amount of a tumour marker may mean that a person has a biliary tract cancer.

Tumour marker tests can be used to diagnose either gallbladder or bile duct cancer and check if treatment is working.

The following tumour markers may be measured for both gallbladder and bile duct cancer:

• Carbohydrate antigen 19-9 (CA19-9)

• Carcinoembryonic antigen (CEA)

Find out more about tumour marker tests.

An ultrasound uses high-frequency sound waves to make images of parts of the body. It's used to view the biliary tract and check for cancer or other problems in people with right-side upper abdominal pain, jaundice or other signs and symptoms of biliary tract cancers.

An abdominal ultrasound is often the first imaging test done when your healthcare team thinks you have either gallbladder or bile duct cancer. It's used to determine the size of the tumour, how much it has spread and if any lymph nodes are bigger than normal (which may indicate cancer has spread there). An ultrasound can also be used to see if cancer has spread to the liver.

An endoscopic or laparoscopic ultrasound may be done if a more detailed image of the gallbladder or bile duct is needed.

Find out more about ultrasounds.

A computed tomography (CT) scan uses special x-ray equipment to make 3D and cross-sectional images of organs, tissues, bones and blood vessels inside the body. A computer turns the images into detailed pictures.

An abdominal CT scan is used to check for biliary tract cancers and determine where in the biliary tract the cancer is. It is also used to see if cancer has spread to nearby lymph nodes, the liver, or other parts of the abdomen.

Find out more about CT scans.

Cholangiography is a procedure used to view the inside of biliary tract to look for blockages such as gallstones or cancer. There are several types of cholangiography that use different imaging techniques to view the biliary tract.

An ERCP (endoscopic retrograde cholangiopancreatography) is a procedure that uses an endoscope (a thin, tube-like instrument with a light and lens that is passed through the mouth) and x-ray to look at the biliary tract and pancreatic ducts. An ERCP is done under general anesthesia.

During an ERCP, a thin tube is placed through the endoscope to inject dye into the pancreatic ducts, which lets doctors see them more clearly on the x-ray.

An ERCP may be used to:

• determine what is blocking the biliary tract
• remove a blockage (if possible)
• collect a sample of cells by scraping the inside of the bile ducts using a special brush (a type of biopsy called bile duct brushing)
• help plan surgery
• place a small tube (stent) into the bile duct to relieve a blockage

Find out more about an ERCP.

An MRCP (magnetic resonance cholangiopancreatography) is a special type of MRI (magnetic resonance imaging) used to take detailed pictures of the biliary tract and pancreatic ducts. It may be used to determine what is blocking the biliary tract and if it can be removed. An MRCP is a non-invasive procedure, so you won't need anesthesia.

A PTC (percutaneous transhepatic cholangiography) may be done to look at the biliary tract and pancreatic ducts on an x-ray. To do a PTC, the surgeon pushes a thin needle through the skin into the abdomen around the gallbladder and bile ducts. The needle injects a special dye into the ducts so they can be seen more clearly on the x-ray. A PTC is done under general anesthesia.

A PTC may be done for the same reasons as an ERCP.

Magnetic resonance imaging (MRI) uses powerful magnetic forces and radiofrequency waves to make cross-sectional images of organs, tissues, bones and blood vessels. A computer turns the images into 3D pictures.

An MRI is used to see if biliary tract cancer has spread to nearby structures (for example, the peritoneum) or other organs.

Find out more about an MRI.

During a biopsy, the surgeon removes tissues or cells from the body so they can be tested in a lab. A report from a pathologist will show whether or not cancer cells are found in the sample.

Sometimes the surgeon won't do a biopsy before treatment because they're concerned that the cancer may spread if tissue is removed. Imaging tests, such as an ultrasound and a CT scan, can often provide enough information to show if there's a cancerous gallbladder or bile duct tumour, and the surgeon can then decide how to treat it.

A biopsy for biliary tract cancer can be done through an ERCP, PTC or fine needle aspiration (FNA).

Find out more about a biopsy.

To do a fine needle aspiration (FNA), the surgeon inserts a very fine needle through the skin of the abdomen and into the gallbladder or liver. An ultrasound or CT scan is used to guide the needle during the procedure.

An FNA may be used to confirm the diagnosis of gallbladder or bile duct cancer if other tests have shown that the cancer has already spread to other organs or cannot be completely removed with surgery (unresectable).

Learn more about fine needle aspiration (FNA).

Find out more about a diagnosis. To make the decisions that are right for you, ask your healthcare team questions about diagnosis.