Makindo Medical Notes

🫙 Gallbladder carcinoma is a rare but highly aggressive malignancy. It is often detected late due to non-specific symptoms and its deep anatomical location. Risk factors include gallstones, porcelain gallbladder, chronic inflammation, and geographic clustering (South America, Northern India, Japan). Prognosis is generally poor, but early surgical detection offers the best outcomes.

📖 About

• Accounts for ~1–2% of all GI cancers, but is the most common biliary tract malignancy.
• Strongly associated with gallstones and chronic inflammation.
• Typically presents in the 6th–7th decade of life, with female predominance (F:M ≈ 3:1).

⚠️ Aetiology / Risk Factors

• 🪨 Gallstones: Present in up to 80% of cases; chronic irritation → dysplasia → carcinoma.
• 🪨🔵 Porcelain gallbladder: Calcified wall; risk of malignancy up to 25%.
• 👵 Age & Gender: More common in elderly women.
• 🌍 Ethnic/Geographic: High prevalence in South America (Chile), Northern India, Japan, Native American populations.
• 🔥 Chronic cholecystitis: Longstanding inflammation → metaplasia → carcinoma.
• 🌱 Gallbladder polyps: >1 cm size = high risk of malignant transformation.
• ♻️ Congenital anomalies: e.g. anomalous pancreaticobiliary duct junction.

🔬 Pathology

• Histology:
  • ~90% adenocarcinoma (tubular, papillary, mucinous subtypes).
  • ~10% squamous or adenosquamous carcinoma.
• Spread:
  • Direct invasion → liver, bile ducts, duodenum.
  • Lymphatic spread → cystic duct, portal nodes.
  • Haematogenous → liver, peritoneum.

🩺 Clinical Presentation

• RUQ pain (often chronic, mimicking gallstones).
• Anorexia, weight loss, malaise.
• Jaundice (if biliary obstruction).
• Nausea, vomiting, fever.
• Pale stools, dark urine (cholestasis).
• Sometimes discovered incidentally after cholecystectomy (“incidentaloma”).

🔍 Investigations

• Ultrasound: First-line; may show mass, polyp, or wall thickening.
• CT/MRI: Staging, local invasion, liver involvement.
• MRCP/ERCP: Biliary tree involvement, therapeutic stenting.
• Endoscopic Ultrasound (EUS): For local assessment, fine-needle aspiration.
• Biopsy: Confirms histology (often intraoperative or via EUS).
• Tumour markers: CA 19-9 and CEA – not diagnostic but helpful in monitoring.

🛠️ Management

• Surgery (only curative option):
  • Early disease: Simple cholecystectomy (stage T1a).
  • Invasive disease: Extended cholecystectomy = cholecystectomy + wedge resection of liver segments IVb/V + lymphadenectomy.
• Chemotherapy: Gemcitabine + cisplatin commonly used for advanced/unresectable disease.
• Radiotherapy: Occasionally used as adjunct or palliative therapy.
• Palliation: Biliary stenting, pain control, nutrition optimisation, supportive care.

📊 Prognosis

• Overall 5-year survival: <10% (due to late presentation).
• Stage I disease: up to 80% survival with curative surgery.
• Most patients present with advanced, unresectable disease → survival often measured in months.

📚 Teaching Commentary

💡 Key exam points:
– Think gallbladder carcinoma if an elderly woman with gallstones presents with constitutional symptoms + jaundice rather than typical biliary colic.
– Porcelain gallbladder is a red flag: most examiners expect you to mention it as a pre-malignant state.
– Always consider gallbladder polyps >1 cm for elective cholecystectomy due to high malignant risk.

🩺 In practice: The majority are discovered incidentally during or after cholecystectomy. Multidisciplinary team (MDT) input is crucial for deciding on re-resection or palliation.