Gallbladder cancer

The gallbladder is a small pouch under the liver that stores bile and releases it into the bowel when fatty food arrives. Tumours in it are rare, and that is one of the few pieces of good news on this page. Everything else is harder: the gallbladder sits deep, its wall is thin and it gives almost no signals of its own, so the illness runs silently for a long time and far too often turns up already spread. A sizeable share of these tumours is found by accident, when the gallbladder is removed for stones and later examined under the microscope. That is exactly why it is worth knowing which signs deserve attention, and why jaundice cannot be left.

Why the illness stays quiet for so long

The reason lies in how the organ is built. The gallbladder wall is very thin and lacks the muscular layer that, in the stomach or bowel, holds a tumour back for a while. The liver lies right against it, so the tumour spreads there before it starts interfering with digestion. As long as the inside of the gallbladder remains clear, a person feels nothing.

The first noticeable complaints usually come not from the tumour itself but from what it blocks: bile stops draining and jaundice develops. By that point the disease is rarely early. In some people symptoms never get the chance to appear at all — the stones ached for years, the gallbladder was taken out, and the tumour was found in the removed tissue.

There is another trap: the early signs resemble things the person has felt before from stones, gastritis or an irritable bowel, and a familiar complaint is easily blamed on its familiar cause. The rule is simple — what matters is not the symptom but its change. The old pain has become different, longer, stronger, or something new has been added to it.

Signs worth showing to a doctor

• Jaundice is the most important sign. The whites of the eyes and the skin turn yellow, urine darkens to the colour of strong tea, stools by contrast go pale, and the skin begins to itch, sometimes unbearably. On brown and black skin the yellow tinge is hard to see, but it shows clearly in the whites of the eyes and under the tongue.
• A dull ache or a sense of heaviness under the right ribs, sometimes felt in the right shoulder blade.
• Loss of appetite and weight loss without trying.
• Nausea, vomiting, bloating, a new dislike of fatty food.
• A lump that can be felt under the right costal margin.
• Fever, chills, night sweats.
• Constant tiredness that rest does not fix.

Jaundice, dark urine and pale stools are a reason to see a doctor the same day, whether or not there is pain. Call an ambulance (in European countries, the single number 112) if jaundice comes with a high fever and shivering, severe abdominal pain, confusion or sudden weakness: that is how infection of the bile ducts behaves, and it is an acute condition treated straight away.

Do not put off an appointment beyond two or three weeks if you are losing weight with no explanation, if your appetite has gone, if long-standing abdominal complaints have changed in character, or if the treatment that always worked has stopped working. The overwhelming majority of such cases will turn out to be anything but a tumour — but they are worth checking, because a disease found early is treated quite differently from one found late.

What raises the risk

Explaining why a tumour appeared in one particular person is usually impossible. Something else is known: almost everything that raises the risk involves years of inflammation in the gallbladder wall.

• Gallstones are the commonest companion of this illness, especially large ones and ones that have been there a long time. The caveat matters: a great many people have stones and gallbladder cancer is rare, so stones by themselves predict almost nothing and are not a reason to have surgery out of fear.
• Gallbladder polyps: small ones are harmless and only need watching; large and growing ones are removed along with the gallbladder.
• A "porcelain" gallbladder, its wall calcified after prolonged inflammation.
• Long-standing inflammation of the bile ducts, including primary sclerosing cholangitis.
• Congenital variants of the ducts that let pancreatic juice wash back into the gallbladder, and cysts of the bile ducts.
• Chronic carriage of certain bowel infections, above all typhoid fever.
• Age: it is hardly seen before fifty and becomes markedly commoner in older groups.
• Being female: women are affected roughly twice as often as men.
• Obesity, diabetes and smoking.
• Work with certain industrial chemicals, in the rubber and textile industries.
• Cases of this illness in a parent, brother or sister.

Geography counts too: in some countries of South America and southern Asia the disease is several times commoner than in Europe, and origin in those regions is taken into account when assessing risk. Little on this list can be changed, but some of it can: do not smoke, keep your weight in check, treat diabetes, and do not postpone a planned gallbladder removal if stones keep inflaming it again and again.

How it is investigated

The conversation usually starts with a primary care doctor, who asks questions, feels the abdomen and orders blood tests: a full blood count, liver function and bilirubin. If a tumour is suspected you are referred to a specialist, and from there the work-up moves quickly.

• Abdominal ultrasound is the first step: available, painless, and it shows stones, wall thickening and dilated ducts alike.
• CT and MRI, including a sequence made specifically for the bile ducts, show the size of the tumour and the state of the liver, the lymph nodes and the vessels.
• Endoscopic ultrasound: the probe is brought close to the gallbladder from inside, through the stomach and duodenum, and samples can be taken at the same time.
• A biopsy is not always taken: if the tumour looks removable, surgeons often prefer to operate without a needle going in first.
• Diagnostic laparoscopy: a look inside the abdomen through a few small cuts before major surgery.
• Blood tumour markers do not make the diagnosis on their own: they also rise in benign bile duct disease. They are used as an addition and for following the picture over time.

Waiting for results is the hardest part, and it often stretches into weeks. A long wait by itself means nothing bad. If the anxiety becomes unbearable, ask who is handling your case and when an answer is due — those are questions people are obliged to answer. It is worth bringing someone close to the appointment where results are discussed: what is heard is poorly retained, and two people remember more.

How it is treated

The plan depends on where the tumour sits, how far it has grown through the wall, whether the liver, the lymph nodes or other organs are involved, and on how robust the person is overall. The decision is not made by one doctor but by a team: surgeon, oncologist, radiotherapy specialist, radiologist and pathologist.

• Surgery is the only way to remove the tumour completely. At an early stage the gallbladder is taken out; when the disease is more advanced, so are the adjoining part of the liver and the surrounding lymph nodes. It is major surgery, undertaken only if the tumour can be removed whole.
• Chemotherapy is used after surgery to reduce the chance of return, and as the main treatment when operating is not possible.
• Radiotherapy is used less often, combined with chemotherapy or to ease pain.
• Targeted drugs and immunotherapy are a relatively new avenue. Tumour tissue is tested for particular molecular features, and if they are present, extra treatment options open up. Asking your oncologist whether that testing was done is a sensible question.
• Restoring bile drainage. If the duct is squeezed shut, a stent is placed inside it to hold the channel open. This does not treat the tumour, but it clears the jaundice and the exhausting itch, and often gives back the ability to eat normally.

A separate and very common story is the tumour found in a gallbladder that has already been removed: it was taken out for stones, and the pathologist found cancer cells in the wall. In that situation a second, more extensive operation is often needed, to take the gallbladder bed in the liver and the lymph nodes. A specialist team decides, and the key thing is not to lose time between the two procedures.

What helps you live through treatment

Care aimed at how you feel is not saved "for later" and does not mean treatment has ended: it runs in parallel, and the earlier it starts, the better everything else is tolerated.

• The itch of jaundice wears people down more than pain does. Besides draining the duct, certain medicines help, along with cool water, loose clothing and short fingernails.
• Eating. Without a gallbladder and with blocked ducts, fat is absorbed less well: small frequent meals are tolerated better than large infrequent ones. If there is persistent diarrhoea with pale, greasy stools, enzymes may be prescribed. A dietitian is more useful on this team than people expect.
• Pain is treated in steps, and there is no point enduring it: adjusting pain relief is routine work, not a last resort.
• Nausea, weakness and weight loss can also be treated — mention them without waiting for the next scheduled visit.
• Palliative care teams deal with quality of life, not only with its final weeks. Bringing them in early eases symptoms and lifts some of the load off the family.
• Support from those close to you and from patient groups, psychological help, and conversations with the nurse handling your case are not luxuries. Ask who to contact between appointments.

Online consultation

A remote appointment neither makes nor excludes this diagnosis — that needs imaging, blood tests and a doctor's hands. It is useful at several points, though. Before any investigation, the doctor will go through your symptoms, say which of them require being seen in person the same day, explain where the work-up usually starts, and suggest which tests are worth having in hand so that weeks are not lost. If stones or a polyp have been found and you are unsure whether anything needs doing, an online appointment is a good place to talk it through calmly, including the sizes that are simply watched and the sizes that are operated on. Once a diagnosis exists, the doctor can help you make sense of unfamiliar words in a report, prepare questions for the oncologist and understand what the proposed options mean. And during treatment it is a convenient way to manage side effects, itching, nausea, eating and pain without an extra trip to the clinic. Jaundice with a high fever, severe abdominal pain and confusion, by contrast, is not a subject for messages: it is an emergency.

This material is for information only and does not replace medical advice.