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Tuesday, March 11, 2008

Stones, Strictures and Cancer of the Bile Ducts

The bile ducts connect the liver to the intestine and their function is to drain the bile, a waste product of normally functioning liver cells (hepatocytes). Diseases of the bile ducts usually result in narrowing of the duct, which is called a stricture. Strictures can be characterized as scaring (primary sclerosing cholangitis, secondary sclerosing cholangitis), traumatic (usually surgical injury), stone forming, or neoplastic (cancerous growths or tumors and polyps). Jaundice or abnormal liver enzyme blood tests are the most common reasons physicians would suspect a problem with the bile ducts.

Cholangiocarcinoma or bile duct cancer arises from the epithelium or lining of the biliary tree either within the liver or in the extrahepatic ducts. Cholangiocarcinoma is an insidious malignancy, which is difficult to cure due to the extent of disease at the time of presentation. Risk factors associated with cholangiocarcinoma include primary sclerosing cholangitis (PSC), ulcerative colitis, liver fluke infestations, chronic cholestasis with chronic stone disease and congenital biliary cystic anomalies. However, many cases are sporadic and have no identifiable etiology. Current methods of staging cholangiocarcinoma include computed tomography (CT), magnetic resonance imaging (MRI), endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). Each has advantages and limitations. A combination of tests can select candidates for surgical resection, which affords long-term survival in a minority of patients.

Relief of biliary obstruction is the mainstay of treatment of most patients with cholangiocarcinoma. Both endoscopic and percutaneous stents are useful in providing adequate biliary drainage. The best approach is dependent upon patient characteristics, location of the tumor and physician expertise. Photodynamic therapy may have a role in selected patients not well palliated by routine stents based on preliminary trials. Limited data exists for the use of chemotherapy or radiation for cholangiocarcinoma. The variable natural history cholangiocarcinoma and small study populations make it difficult to conduct controlled clinical trials. Interpretation of the available data suggests a small survival advantage of chemotherapy and radiation. Liver transplantation is not an effective means of treatment for cholangiocarcinoma due to rapid recurrence of the tumor and decreased patient survival. Occasionally, small tumors can be found incidentally within the explanted liver of transplant patients with PSC and their survival may not be significantly affected.

Via: http://cms.clevelandclinic.org

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