Biochemical parameters of serum indicate cholestatic jaundice. The level of bilirubin, activity of alkaline phosphatase and GGTP can be very high. Their fluctuations may reflect incomplete obstruction or initial involvement of only one hepatic duct.
Anti-mitochondrial antibodies in the serum are not detected, the level of a-OP is not increased.
Cal is discolored, bold, often contains hidden blood. Glucosuria is not present.
Anemia is more pronounced than with carcinoma of the ampoule, but not due to blood loss; the reasons for this are unclear. The level of leukocytes is at the upper limit of the norm, the percentage of polymorphonuclear leukocytes is increased.
When a liver biopsy shows signs of obstruction of large bile ducts. Tumor tissue can not be obtained. The malignancy of the process is very difficult to confirm histologically.
It is important to conduct a cytological study of tissues in the stricture of the bile duct. It is best to perform a brush biopsy with endoscopic or percutaneous interventions or a puncture biopsy under ultrasound or radiographic control. Tumor cells are detected in 60-70% of cases. The study of bile, aspirated directly with cholangiography, is much less important.
In some cases, with the cholangiocarcinoma, the level of the CA19 / 9 oncomarker increases, but there are reports of high levels of this marker also in benign diseases, which reduces its significance for screening studies. More precise can be the simultaneous determination of CA19 / 9 and carcinoembryonic antigen.
Especially important is ultrasound, which allows to detect the expansion of the intra-hepatic ducts. The tumor can be detected in 40% of cases. Ultrasound (in real time, combined with Doppler study) accurately reveals lesion of the portal vein tumor, both occlusion and wall infiltration, but is less suitable for detecting lesions of the hepatic artery. Endoscopic intraprostatic ultrasound is still an experimental method, with its help you can get important information about the spread of the tumor inside and around the bile duct.
CT scan reveals dilatation of intrahepatic bile ducts, but the tumor, whose density does not differ from the density of the liver, is more difficult to visualize. CT allows us to identify shared atrophy and the relative location of the caudate lobe and tumor in the region of the liver gates. The modern method of spiral CT with computer reconstruction allows to accurately determine the anatomical relationships of blood vessels and bile ducts in the gates of the liver.
MRI can detect larger intrahepatic (cholangiocellular) carcinomas, but with extrahepatic location of the tumor, MRI, as compared to ultrasound and CT, has no additional advantages. In some centers, magnetic resonance cholangiography is performed with reconstruction of the bile (and pancreatic) ducts, which can be a very valuable diagnostic method.
Endoscopic or percutaneous cholangiography or a combination thereof is of great importance in diagnosis; they should be performed in all patients with clinical signs of cholestasis and signs of enlargement of intrahepatic bile ducts, detected with ultrasound or CT.
The tumor can be detected by cytologic examination or transpapillary gingival biopsy during ERCP.
With endoscopic retrograde cholangiography, normal common bile duct and gall bladder, as well as obstruction in the gates of the liver, are revealed.
Percutaneous cholangiography. Obstruction looks like a sharp breakage of the duct or in the form of a nipple. Intrahepatic bile ducts are dilated in all cases. If obstruction develops only in the right or left hepatic duct, it may be necessary to puncture both ducts for precise localization.
With the help of digital subtraction angiography, it is possible to visualize the hepatic artery and portal vein, as well as their intrahepatic branches. This method is still of great importance for preoperative assessment of tumor resectability.
With the growth of cholestatic jaundice, the most likely clinical diagnosis of carcinoma of the periampull region. In addition, drug jaundice, primary sclerosing cholangitis and primary biliary cirrhosis are possible. Although such a course for cholangiocarcinoma is uncharacteristic, with systematic diagnostic search it should be excluded. Data from anamnesis and objective examination usually do little to help in diagnosis.
The first stage of the examination with cholestasis is ultrasound. With cholangiocarcinoma, the enlargement of the intrahepatic bile ducts is revealed. The common bile duct may be unchanged, the changes may be questionable, or the duct may be dilated below the extrahepatic tumor. To establish the level and parameters of stricture perform percutaneous or endoscopic cholangiography, cytological examination and biopsy.
Sometimes patients with cholestasis are referred for surgery without performing cholangiography, since the cause of obstruction - pancreatic carcinoma or stones - is determined by other imaging methods. If the common bile duct is not changed, when palpation of the gates of the liver, the pathology is not detected and the cholangiogram (without filling the intrahepatic bile ducts) is not changed, the diagnosis causes depression. The volumetric formation in the region of the liver gates is too high and too small to be detected. We should pay due attention to such signs as an enlarged green liver and a sleeping gallbladder.
If a patient with cholestasis does not have an enlarged bile duct with ultrasound, other possible causes of cholestasis should be considered, including jaundice (anamnesis) and primary biliary cirrhosis (antimitochondrial antibodies). A histological examination of liver tissue is useful. If primary sclerosing cholangitis is expected, the main diagnostic method is cholangiography. In all patients with cholestasis without dilated bile ducts, in which the diagnosis is unclear, ERCP should be performed.
Scanning and cholangiography allow to diagnose the stricture of the bile ducts caused by cholangiocarcinoma. When lesion of the area of the gates of the liver, a differential diagnosis is made between metastasis in the lymph node, carcinoma of the pancreatic duct and pancreatic carcinoma in the periapulary region, taking into account the anamnesis and the results of other imaging methods.
Definition of tumor stage
If the patient's condition allows surgery, the resectability and size of the tumor should be assessed. It is necessary to detect metastases, which are usually late.
Lesions of the lower and middle sections of the common bile duct are usually resectable, although angiography and venography should be performed to avoid invasion of the vessels.
The more common cholangiocarcinoma of the liver gates creates more problems. If cholangiography shows a lesion of the hepatic ducts of the second order of both liver lobes (type IV) or if the tumor spreads around the main trunk of the portal vein or the hepatic artery, the tumor is not resectable. In these cases, palliative intervention is indicated.
If the tumor is confined to the bile duct bifurcation area, it affects only one lobe of the liver or squeezes the branch of the portal vein or the hepatic artery on the same side, resection is possible. Preoperative imaging studies are necessary in order to understand if the liver will retain after resection of viability. The remaining segment of the liver must have a fairly large duct that can be anastomosed with the intestine, an intact branch of the portal vein and the hepatic artery. During the operation, an additional ultrasound and an examination are performed to exclude lymph node involvement.
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