Gallbladder Cancer - Infographic

Gallbladder cancer is a rare cancer in which malignant (cancer) transformation of cells occur in the wall of the gallbladder. The gallbladder is a pear-shaped organ under the liver that stores bile. Bile or gall is a fluid produced by the liver to digest fats. Certain ethnic groups e.g. Native American Indians and Hispanics also suffer a greater incidence of the cancer. Women are at affected more than men. Cure is possible if diagnosis is done early enough.

What is Gallbladder Cancer?

Gallbladder cancer is a rare cancer in which malignant (cancer) transformation of cells occur in the wall of the gallbladder.

The gallbladder is a pear-shaped organ under the liver that stores bile. Bile or gall is a fluid produced by the liver to digest fats. It is more commonly seen in central and South America, central and Eastern Europe, Japan and northern India. Certain ethnic groups e.g. Native American Indians and Hispanics also suffer a greater incidence of the cancer.Women are at affected more than men. Cure is possible if diagnosis is done early enough. Unfortunately a diagnosis is often made once symptoms occur, i.e. after the cancer advances. In such cases the outlook is poor. Surgery is the most effective treatment. Radiation and chemotherapy are also used. 

Risk factors of gallbladder cancer include:

• Gender: Gallbladder cancer is twice more common in women than men. It mostly occurs between the ages of 50 and 60
• Obesity: Obesity increases the risk of getting the cancer
• Ethnic groups: Ethnic groups like Native American Indians and Hispanics are at a high risk

The cancer is thought to be related to the presence of gallstones. Gallstones lead to calcification of the gallbladder. This condition is called ‘Porcelain gallbladder’. People with porcelain gallbladder are at a high risk developing the cancer.

Signs and Symptoms

Jaundice, pain and fever may be the pointers to gallbladder cancer. But these are not disease specific. The triad of these three symptoms is called the Murphy’s Triad and it specifically occurs in a condition called Cholangitis (infection of the common bile duct that carries bile).

The early stages of gallbladder cancer may not produce any noticeable signs or symptoms.

Gallbladder cancer symptoms and signs include:

• Jaundice, where yellowing of the skin and whites of the eyes occurs
• Pain above the stomach
• Fever
• Nausea and vomiting
• Bloating
• Lumps in the abdomen

DIAGNOSIS

An early diagnosis of gallbladder cancer is difficult since the early stages of the cancer go unnoticed due to the lack of specific signs or symptoms. The clinical features produced by gallbladder are mimicked by a number of other conditions. Early symptoms mime gallbladder inflammation due to gallstones. The later symptoms are similar to those produced by biliary and stomach obstruction.

The cancer may be an incidental finding when the gallbladder is removed for other reasons or if an ultrasound may show a mass in the gall-bladder.

Diagnosis begins with physical examination and elicitation of history. Signs of the disease, such as lumps are searched for.

Once suspected an ultrasound examination of the abdomen helps in diagnosis gallbladder cancer. Other Imaging techniques employed include:

• CT scan
• MRI scan
• ERCP (endoscopic retrograde cholangiopancreatography): This aids in visualizing the duct system that carry bile
• Chest X-ray
• Percutaneous transhepatic cholangiography (PTC) is used to x-ray the liver and bile ducts
• Laparoscopy aids in direct visualization of organs
• Liver function tests are performed to know if the liver has been affected due to gallbladder cancer
• Levels of Carcinoembryonic Antigen (CEA) are checked for. CEA is a protein produced by both cancer cells and normal cells. Higher levels of CEA may indicate gallbladder cancer or other conditions
• Another similar test is CA 19-9 assay. CEA and CA 19-9 are referred to as ‘tumour markers’

PROGNOSIS

The outlook (prognosis) and treatment options of gallbladder cancer depend on a number of factors.

• The stage of the cancer: The extent of the cancer plays a vital deciding role. Other important questions one may need to ask include whether the cancer has been diagnosed early; whether it is a recurrent case
• Whether complete surgical removal is possible
• The type of gallbladder cancer (based on microscopy)
• The general health of the patient

Staging is an important part of cancer management. Gallbladder cancer may be localized (stage 1) or not resectable (stages II, III and IV). Localized cancer can be completely removed surgically.

A recurrent gallbladder cancer is one that has reappeared after complete treatment.

Advanced stages have poor prognosis. The median survival for advanced disease is short (2-4 m)

TREATMENT

Surgical removal may be the most common and most effective treatment of gallbladder cancer. A completely curative resection is however possible only in a minority of patients. This is because most patients present in an advanced stage of the cancer when surgery may not be possible.

When possible, gallbladder and nearby tissues (including lymph nodes) are removed. Surgery is associated with significant mortality and morbidity. In cases where operative removal is not possible, alternatives are called in:

• Surgical biliary bypass: a new pathway for drainage of bile is created
• Endoscopic stent placement: A stent (thin, flexible tube) is used to drain the bile into the small intestine
• Percutaneous transhepatic biliary drainage: this is also a procedure for draining bile

These procedures relieve the patient of jaundice.

Apart from surgery, radiation therapy and chemotherapy are also available.

Radiation Therapy

Radiation therapy is a cancer treatment where high-energy x-rays or other types of radiation are used to kill cancer cells or prevent them from growing. There are two types of radiation therapy.

In External radiation therapy, a machine outside the body is used to send radiation toward the cancer. The total dose of radiation therapy is sometimes divided into several smaller, equal doses which are delivered over a period of time spanning over several days. In Internal radiation therapy, a radioactive substance is placed directly into or near the cancer. The type of radiation therapy used depends on the type and stage of the cancer being treated.

Chemotherapy

Here drugs are used to stop the growth of cancer cells, either by killing the cells or by preventing them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body, this is called systemic chemotherapy. In regional chemotherapy drugs are placed directly into the spinal column, an organ, or a body cavity.

A new modality being tested in clinical trials is the use of radio-sensitizers:

Radio-sensitizers

These drugs are used in combination with radiation therapy so that a larger number of tumor cells can be killed. Radio sensitizers increase the sensitivity of cancer cells to radiation.

COMPLICATION OR SIDE EFFECTS OF GALLBLADER  

SURGERY

Gallbladder Surgery Recovery Time

The patient recovers much faster after a laparoscopic surgery than after an open surgery. Laparoscopic surgery is less painful and the patient can leave the hospital on the same day or the day after the surgery. He/she may proceed with their daily routine activities within a period of two weeks and may be able to do strenuous exercises after a month.

However, it takes a longer time to recover after an open cholecystectomy. Patients spend around 2 to 4 days or even longer in the hospital and it takes at least four to six weeks for the patients to get back to routine activities.

Gallbladder Surgery Complications

Both open and laparoscopic surgeries of the gallbladder are considered as relatively safe procedures. As can be expected, the overall risk associated with a laparoscopic surgery is much less in comparison to an open surgery.

The most common side effects following surgery are gas problems, indigestion, abdominal pain, bloating and diarrhea, especially after eating fatty and spicy food.


Diarrhea following gall bladder surgery usually improves over time, but in very few cases may last for several years. Diet rich in fiber content is recommended in such cases.

More serious complications include-

• Infection of the surgical incision or deeper tissues

• Injury to surrounding structures like the common bile duct, small or large intestine during surgery. Injury to the common bile duct can result in bile leakage.

• Excessive bleeding

• Inflammation of the pancreas (pancreatitis)

• Complications associated with the general anesthesia like blood clots in the legs or lungs, breathing or heart problems, pneumonia and drug reaction.

T

DIET SHIULD BE FALLOWED AFTER GALLBLADDER 

SURGERY

A low fat diet is recommended for several weeks before a gallbladder surgery. Some diet restrictions are also recommended following gallbladder surgery:

• After the surgery a bland, low fat diet is considered to be the most ideal and may include toast, rice, bananas, soup and pasta.

• Once the patient is fully recovered, a healthy and balanced diet that includes fresh fruits, vegetables and whole grains is recommended.


• Foods rich in fat such as whole milk, cream, cakes and deep-fried foods should be avoided. Instead skimmed milk, low fat yogurt, baked meat or fish and non-alcoholic beverages should be included in the diet.


• Healthy fats such as olive oil and fish oil should be used.

Besides, addition of bile supplement to the meals may help in digestion.

FREQUENTLY  ASKED QUESTIONS

1. Which doctors do gallbladder surgery?

Gallbladder surgery may be done by a surgeon or a surgical gastroenterologist.

2. Which is the most preferred type of gall bladder surgery during pregnancy?

Gallbladder surgery during pregnancy is usually avoided and is done only in case of an emergency. If the pregnancy is in the last trimester, an open surgery is usually preferred.

3. Which are the various conditions in which a laparoscopic surgery is not recommended?

Laparoscopic gallbladder surgery should be avoided in the presence of lung infection or disease, obesity, bleeding problems, pancreatitis, severe liver problems, third trimester of pregnancy or if the patient has undergone past surgeries of the abdomen.

4. What is the diet recommended for patients with diarrhea after a gallbladder surgery?

A diet rich in fibre content such as brown rice and whole meal bread is recommended for patients with diarrhea following gallbladder surgery. A low fat and less spicy diet is also recommended for these patients.

HOW IS GALLBLADER SURGERY DONE

The surgical removal of gallbladder is called cholecystectomy. It is done for certain symptomatic cases of gallstones or cases of structural or functional abnormalities of the gallbladder.


There are two main ways of performing a gallbladder surgery, laparoscopic cholecystectomy and open cholecystectomy.

Before the Surgery:

Before the surgery, the patient may have to undergo tests to confirm the gallbladder pathology. For example, ultrasound may be used to diagnose gallstones. Other tests like blood tests, x-rays, and ECG are also usually done.

As with other surgeries, certain medications that could interfere with clotting of blood post-surgery like aspirin and warfarin should be stopped prior to the surgery. A low fat diet several weeks before the surgery is advised.

Laparoscopic Cholecystectomy:

Laparoscopic cholecystectomy is also known as keyhole surgery and is done with an instrument called the laparoscope. A laparoscope is a lighted scope which is attached to a video camera and is inserted through a small incision in the abdomen. The abdomen is inflated with air or carbon dioxide so that the surgeon can get a clear view. The video monitor guides the surgeon during the operative procedure.

Situations where a laparoscopic cholecystectomy should be avoided include the presence of lung infection or disease, obesity, bleeding problems, pancreatitis, severe liver problems, third trimester of pregnancy or if the patient has undergone past surgeries of the abdomen.

Open Cholecystectomy:

Sometimes, laparoscopic surgery is not possible due to associated medical problems; an open cholecystectomy is recommended in such situations. A laparoscopic procedure may also be converted to an open procedure if the surgeon encounters some problems during the surgery.

In open cholecystectomy, the surgeon makes one large (5- to 7- inch) incision in the upper right part of the abdomen just below the ribcage. The bile duct and the blood vessels attached to the gall bladder are then cut. The surgeon removes the gall bladder by gently lifting it and separating it from the other organs.

After the surgery, since the gall bladder has been removed, bile flows directly from the liver through the common bile duct to the small intestine. Hence, the removal of gall bladder usually does not have a significant effect on digestion.


Both laparoscopic and open cholecystectomy are done under general anesthesia.

A special X-ray known as cholangiogramis performed before gallbladder surgery. This X-ray procedure makes use of a dye to study the anatomy of the bile ducts and detect any pathology like gallstones