Gallbladder Carcinoma, Improving Diagnosis and Outcome

Abstract

Objective: The purpose of this study is to determine the pattern of presentation of carcinoma of the gall bladder in Saudi patients and to assess the accuracy of diagnostic modalities, namely ultrasound and computerized scan, in detecting the disease, together with an extensive literature review to establish suspicious criteria helping in early diagnosis of this lethal disease.Methods: This is a retrospective study of patients diagnosed to have gallbladder carcinoma at King Fahad Medical City, Riyadh, K.S.A. in the period from January 2007 to January 2010.Results: Six patients were included, 5 females and one male (age range between 58 and 87 years, with a mean age of 73 years. The main presenting symptoms were abdominal pain (83.3%), nausea and vomiting (50%). Two patients were found to be jaundiced (33.3%), an abdominal mass was felt in one patient (16.6 %) and weight loss was seen in 4 patients (66.7%). Liver function test showed abnormal liver enzymes in 3 patients (50%), elevated bilirubin in two patients (33.3%), elevated alkaline phosphatase in 4 patients (66.7%) and low albumin in all patients (100%). Low hemoglobin was observed in 2 patients (33.3%). abdominal ultrasound was suspicious for gallbladder carcinoma in two patients (33.3 %), gallstones and chronic cholecystitis were found in the remaining 4 patients. CT scan was performed in 4 patients and it was suspicious of gallbladder cancer in all of them (100%). It detected evidence of liver invasion and hepatic metastasis in one of the 2 operated cases; however, it failed to detect liver invasion in one of the operated patients who subsequently was proved to have liver invasion on histological examination of the liver resection specimen. Histology confirmed diagnosis of adenocarcinoma in all patients with variable degree of differentiation.Conclusions:The poor prognosis of gallbladder cancer is related to its dissemination capacity and usually late diagnosis due to its non-specific clinical presentation. The traditional routine approach of investigation and management of patients with gallbladder stones which depends mainly on ultrasound as diagnostic modality may delay the diagnosis and waste the chance of early detection of gallbladder carcinoma when curative resection is achievable. We recommend a high index of suspicion in patients with gallstones in presence of a combination of female sex, old age, silent gallstones presenting at late age, and thickened wall of the gallbladder on ultrasonic examination. We also recommend adding more sensitive investigation like CT scan, EUS, and ultrasound-guided aspiration cytology/biopsy to the protocol of investigation of these patients.