A rare, accounting for fewer than 1% of all cancers. It’s normally found by accident in patients with cholecystitis; 1 in 400 cholecystectomies reveals a malignant tumor. The disease is most prevalent in females older than age 60. It’s rapidly progressive and usually fatal; patients seldom live a year after diagnosis. The poor prognosis is due to late diagnosis; gallbladder cancer isn’t usually diagnosed until after cholecystectomy, when in many cases it’s in an advanced, metastatic stage.

Gallbladder cancer may result from a complication of gallstones. However, this inference rests on circumstantial evidence from postmortem examinations: 60% to 90% of gallbladder cancer patients also have gallstones, but postmortem data from patients with gallstones show gallbladder cancer in only 0.5%.

The predominant tissue type in gallbladder cancer is adenocarcinoma, 85% to 95%; squamous cell, 5% to 15%. Mixed-tissue types are rare.

Lymph node metastasis is present in 25% to 70% of patients at diagnosis. Direct extension to the liver is common (in 46% to 89%); direct extension to both the cystic and the common bile ducts, stomach, colon, duodenum, and jejunum also occurs and produces obstructions. Metastasis also spreads by portal or hepatic veins to the peritoneum, ovaries, and lower lung lobes.

The cause of extrahepatic bile duct cancer isn’t known; however, statistics report an unexplained increased incidence of this cancer in patients with ulcerative colitis. This association may be due to a common cause — perhaps an immune mechanism, or chronic use of certain drugs by the colitis patient.

Extrahepatic bile duct cancer is the cause of approximately 3% of all cancer deaths in the United States. It occurs in both males and females (incidence is slightly higher in males) between ages 60 and 70. The usual site is at the bifurcation in the common duct. Cancer at the distal end of the common duct is commonly confused with cancer of the pancreas. Characteristically, metastatic spread occurs to local lymph nodes, the liver, lungs, and the peritoneum.

Clinically, gallbladder cancer is almost indistinguishable from cholecystitis — pain in the epigastrium or right upper quadrant, weight loss, anorexia, nausea, vomiting, and jaundice. However, chronic, progressively severe pain in an afebrile patient suggests malignancy. In patients with simple gallstones, pain is sporadic. Another telling clue to malignancy is palpable gallbladder (right upper quadrant), with obstructive jaundice. Some patients may also have hepatosplenomegaly.

Progressive profound jaundice is commonly the first sign of obstruction due to extrahepatic bile duct cancer. The jaundice is usually accompanied by chronic pain in the epigastrium or the right upper quadrant, radiating to the back. Other common signs or symptoms, if associated with active cholecystitis, include pruritus, skin excoriations, anorexia, weight loss, chills, and fever.

No test or procedure, by itself, can diagnose gallbladder cancer. However, the following laboratory tests support the diagnosis when they suggest hepatic dysfunction and extrahepatic biliary obstruction:

❑baseline studies — complete blood count, routine urinalysis, electrolyte studies, enzymes

❑ liver function tests — typically reveal elevated serum bilirubin, urine bile and bilirubin, and urobilinogen levels in more than 50% of patients as well as consistently elevated serum alkaline phosphatase levels

❑ occult blood in stools — linked to the associated anemia

❑ cholecystography — may show calculi or calcification

❑ cholangiography — may locate the site of common duct obstruction

❑ magnetic resonance imaging — detects tumors.

The following tests help compile data that confirm extrahepatic bile duct cancer:

❑ liver function studies — indicate biliary obstruction: elevated levels of bilirubin [5 to 30 mg/dl], alkaline phosphatase, and blood cholesterol as well as prolonged prothrombin time

❑ endoscopic retrograde cannulization of the pancreas — identifies the tumor site and allows access for obtaining a biopsy specimen.

Surgical treatment of gallbladder cancer is essentially palliative and includes various procedures, such as cholecystectomy, common bile duct exploration, T-tube drain-age, and wedge excision of hepatic tissue.

If the cancer invades gallbladder musculature, the survival rate is less than 5%, even with massive resection. Although some cases of long-term survival (4 to 5 years) have been reported, few patients survive longer than 6 months after surgery for gallbladder cancer.

Surgery is normally indicated to relieve obstruction and jaundice that result from extrahepatic bile duct cancer. The procedure used to relieve obstruction depends on the cancer site. Such procedures may include cholecystoduodenostomy or T-tube drainage of the common duct.

Other palliative measures for both kinds of cancer include radiation, radiation implants (mostly used for local and incisional recurrences), and chemotherapy (with combinations of fluorouracil, irinotecan, and gemcitabine). All of these treatment measures have limited effects.

After biliary resection:

❑Monitor vital signs.

❑Use strict sterile technique when caring for the incision and the surrounding area.

❑Place the patient in low Fowler’s position.

❑Prevent respiratory problems by encouraging deep breathing and coughing. The high incision makes the patient want to take shallow breaths; using analgesics and splinting his abdomen with a pillow or an abdominal binder may aid in greater respiratory efforts.

❑Monitor bowel sounds and bowel movements. Observe the patient’s tolerance to diet.

❑Provide pain control.

ELDER TIP Check intake and output carefully. Watch for electrolyte imbalance; monitor I.V. solutions to avoid overloading the cardiovascular system, especially in older patients.

❑Monitor the nasogastric tube, which will be in place for 24 to 72 hours postoperatively to relieve distention, and the T tube. Record amount and color of drainage each shift. Secure the T tube to minimize tension on it and prevent its being pulled out.

❑Help the patient and his family cope with their initial fears and reactions to the diagnosis by offering information and support.

❑Before discharge, teach the patient how to manage the biliary catheter.

❑Advise the patient of the adverse effects of both chemotherapy and radiation therapy, and monitor him for these effects.

❑When all treatments have failed, concentrate on keeping the patient comfortable and free from pain and provide as much psychological support as possible. If the patient is going home, discuss continuing care needs with the caregiver or refer the patient to an appropriate home health care or hospice agency. Encourage the patient and caregiver to express their feelings and concerns. 

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