Saturday, February 17, 2024

Pancreatic Cancer Blocking Bile Duct

Symptoms Of A Blocked Bile Duct

What happens to the stent that is placed in the bile duct? (Kulwinder Dua, MD)

In about 7 in 10 cases the tumour first develops in the head of the pancreas. A small tumour often causes no symptoms at first. As the tumour grows it tends to block the bile duct. This stops the flow of bile into the first part of the gut, known as the duodenum, which leads to:

  • Yellow skin – caused by bile seeping into the bloodstream due to the blockage.
  • Dark urine – caused by the jaundiced blood being filtered by the kidneys.
  • Pale stools – as the faeces contain no bile which causes their normal brown colour.
  • Generalised itch – caused by the bile in the bloodstream.

Pain is often not a feature at first. Therefore, a painless jaundice that becomes worse is often the first sign of pancreatic cancer. Feeling sick and being sick are also fairly common symptoms.

Bile Duct Cancer Treatment

This page describes the different types of treatment forbile duct cancer . Which of these treatments a patient receives will depend on whether the cancer can be completely removed with surgery or not . To learn more, see treatment of resectable and treatment of unresectable bile duct cancer.

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Jaundice And Related Symptoms

Jaundice is yellowing of the eyes and skin. Most people with pancreatic cancer will have jaundice as one of their first symptoms.

Jaundice is caused by the buildup of bilirubin, a dark yellow-brown substance made in the liver. Normally, the liver releases a liquid called bile that contains bilirubin. Bile goes through the common bile duct into the intestines, where it helps break down fats. It eventually leaves the body in the stool. When the common bile duct becomes blocked, bile cant reach the intestines, and the amount of bilirubin in the body builds up.

Cancers that start in the head of the pancreas are near the common bile duct. These cancers can press on the duct and cause jaundice while they are still fairly small, which can sometimes lead to these tumors being found at an early stage. But cancers that start in the body or tail of the pancreas dont press on the duct until they have spread through the pancreas. By this time, the cancer has often spread beyond the pancreas.

When pancreatic cancer spreads, it often goes to the liver. This can also cause jaundice.

There are other signs of jaundice as well as the yellowing of the eyes and skin:

Pancreatic cancer is not the most common cause of jaundice. Other causes, such as gallstones, hepatitis, and other liver and bile duct diseases, are much more common.

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Overview Of Pancreatic Cancer

Most Common Types of cancer Check Here

The pancreas is a large gland which produces digestive juices and insulin. The digestive juices flow down a tube within the pancreas and join the intestine at the duodenum. The duodenum is the first part of the small bowel connected to the stomach. The bile duct comes down from the gallbladder and liver and also joins into the duodenum at the same point as the pancreatic duct. The pancreas lies high up in the abdomen. It lies across the body behind the stomach. It is at about the level where the ribs join the bottom of the breast bone.

Pancreatic cancer is relatively uncommon. It affects in 1 in 10,000 people each year in the United Kingdom. There are several different types of pancreatic cancer but the vast majority develop from the cells that line the pancreatic duct. These cancers are described as “adenocarcinomas”.

As cancer cells grow within the pancreatic ducts, they enlarge and can either block the main pancreatic duct or bile duct which lies next to it. This can stop the drainage of pancreatic fluid or bile into the duodenum.

As the cancer grows larger it can invade the tissues around the pancreas such as the duodenum, stomach or liver. Cancer cells can also break away and spread through lymph channels to lymph nodes or to other parts of the body such as the liver, lungs or bones .

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Eating Problems And Weight Loss

You may find it hard to eat well due to the effects of cancer and its treatment. But there are ways to help improve your appetite and make sure you are getting enough calories. Your dietitian will advise you about digestive enzymes and help you manage your diet if you have developed diabetes.

How it’s treated

Pancreatic enzymes in tablet form can help you digest your food so it can be absorbed. Anti-sickness tablets can help if you have nausea. There are also medicines for constipation and diarrhoea. You might be given a special diet, with, for example, lots of high-energy foods.

In rare cases, your doctor may feel a feeding tube is necessary. This may be done if you cannot take in enough calories by mouth. Or your doctor may decide to give you nutrients directly into a vein. This is called total parenteral nutrition . TPN is usually only given if there is a blockage in the bowel.

We have more advice on coping with eating difficulties. Or read our booklet Diet and Cancer for help with eating problems and tips on how to get more calories.

What Is Biliary Obstruction

Biliary obstruction is a blockage of the bile ducts. A duct is a tube that carries specific bodily fluids.

The bile ducts carry bile from the liver and gallbladder through the pancreas to the duodenum, which is a part of the small intestine. Bile is a dark-green fluid secreted by the liver to digest fats, and its stored in the gallbladder.

After you eat, the gallbladder releases bile to help in digestion and fat absorption. Bile also helps clear the liver of waste products.

Obstruction of any of these bile ducts is referred to as a biliary obstruction. Many of the conditions related to biliary obstructions can be treated successfully. However, if the blockage remains untreated for a long time, it can lead to life threatening diseases of the liver.

two types of bile ducts in the liver are:

  • Intrahepatic ducts. Intrahepatic ducts are a system of smaller tubes within the liver that collect and transport bile to the extrahepatic ducts.
  • Extrahepatic ducts. The extrahepatic ducts begin as two parts, one on the right of the liver and the other on the left. As they descend from the liver, they unite to form the common hepatic duct. This runs directly toward the small intestine.

The cystic duct, or the duct from the gallbladder, also opens into the common hepatic duct. The bile duct from this point onward is known as the common bile duct, or choledochus. Before emptying into the small intestine, the common bile duct passes through the pancreas.

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What Is The Treatment For Biliary Obstruction

Treatment is aimed at correcting the underlying cause, and the primary goal of medical or surgical treatment is to alleviate the blockage. Some of the treatment options for a biliary obstruction include a cholecystectomy and an ERCP.

If youve been diagnosed with gallstones, an ERCP may be sufficient to remove small stones from the common bile duct or to place a stent inside the duct to restore bile flow. This method is often used in cases where obstruction is caused by a tumor.

A cholecystectomy, which is the removal of the gallbladder, is another very effective treatment for gallstones.

Other therapies include the removal or treatment of tumors and medication to eradicate parasites.

Without treatment, biliary duct obstructions can be life threatening. Possible complications that can arise without treatment include:

  • chronic liver disease
  • biliary cirrhosis

Contact your doctor right away if you develop jaundice or notice a change in color of your stool or urine.

Using A Duodenal Stent To Treat A Blocked Bile Duct

What is the bile duct, and what is a bile duct obstruction? (Kulwinder Dua, MD)

At some stage, many pancreatic cancer patients find that their tumour begins to compress or restrict the duodenum . This often occurs gradually and begins to cause discomfort after eating and nausea. Fluids may be easier to take then solids. The stomach gradually stretches so that you feel like vomiting slightly less and weight loss occurs as food cannot reach the small intestine for nutrients to be absorbed.

One way to treat this is the use of a billary stent. This is a flexible tube made of either plastic or an expanding metal mesh which helps to keep the bile duct open and allows food and fluid to pass through it. The stent can reduce the discomfort caused by a blocked duodenum, nausea and vomiting.

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What Is Bypass Surgery

If you have cancer that cant be removed by surgery and your bile duct is blocked, you will usually have a stent put in to unblock it. But sometimes surgery called is used to make a new way for bile to flow to the intestines, passing around the blocked bile duct. This is usually done if you were originally having surgery to remove the cancer but that wasnt possible.

Using Stents To Relieve Symptoms

It is also quite common for the bile duct to be blocked by pancreatic cancer. This causes jaundice and may cause severe itching. In this case you might have a stent put in. This is a small metal or plastic tube which which can be inserted by ERCP . It can also be put in through your skin using a method call percutaneous transhepatic cholangiogram .

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Signs And Symptoms Of Pancreatic Cancer

Early pancreatic cancers often do not cause any signs or symptoms. By the time they do cause symptoms, they have often grown very large or already spread outside the pancreas.

Having one or more of the symptoms below does not mean you have pancreatic cancer. In fact, many of these symptoms are more likely to be caused by other conditions. Still, if you have any of these symptoms, its important to have them checked by a doctor so that the cause can be found and treated, if needed.

Eus Guided Biliary Drainage

New Tools In The Battle Against Bile Duct Cancer

Other endoscopic alternatives are being used in relieving malignant biliary obstruction not amenable to stent placement via ERCP. Endoscopic ultrasound-guided biliary drainage has been demonstrated to be a safe and effective means of biliary drainage. EUS-BD can be achieved by multiple techniques including EUS-guided rendezvous, EUS-guided choledochoduodenostomy , and EUS- guided hepatic gastrostomy . In situations when the endoscope can reach the ampulla, rendezvous can be achieved by inserting an FNA needle into the common bile duct or left intrahepatic duct under EUS guidance, followed by navigating a guidewire through the bile duct past the stricture into the duodenum. A duodenoscope can then be used to allow over-the-wire cannulation with ERCP and retrograde stent placement. When the papilla cannot be reached due to malignant obstruction of the duodenum, EUS-CDS and EUS- HGS offer ways to create tracts to the bile duct with extrahepatic and intrahepatic approaches respectively. Both these methods also utilize guidewires that are advanced past the ampulla into the duodenum, which is followed by anterograde dilation of the tract and stent placement. At this time, these procedures remain technically complex and limited to high-volume centers with expertise in therapeutic endoscopy. Complications may include bile leak, bleeding, or pneumoperitoneum. Future trials will further assess the efficacy of these methods and seek to improve their feasibility and safety.

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Alternative Stent Designs And Strategies

Drug eluting stents have been designed in an attempt to improve SEMS patency by eluting a chemotherapeutic agent such as paclitaxel to prevent tumor ingrowth and stent occlusion. Prior studies have shown that they effectively inhibit cells responsible for stent occlusion and can be safely used in animal models and humans. Recently Jang et al conducted a multicenter prospective comparative study to compare the efficacy of this type of stent to covered SEMS in patients with unresectable distal malignant biliary obstruction. In a non-randomized fashion, 60 patients were enrolled into a paclitaxel coated SEMS group while 46 were enrolled to the covered SEMS group. There was no significant difference in rates of stent patency between both groups. There are ongoing efforts to design new drug eluting stents with different chemotherapeutic agents such as gemcitabine. Further trials are needed to determine whether these stents can improve upon the performance of the current generation of SEMSs.

Percutaneous Transhepatic Biliary Drainage

In cases where patients are not candidates for ERCP or have failed attempted transpapillary stent placement, percutaneous transhepatic cholangiography has traditionally been used as a method for biliary drainage. This method can offer the same benefits of biliary decompression in improving patient comfort and preventing adverse outcomes. In most cases an internal-external biliary drain is passed through the site of malignant biliary obstruction to the duodenum, where it can reestablish internal bile drainage and normal enterohepatic circulation. Efforts are made to discontinue the external drainage component unless it continues to have high output or the patient is in a state of sepsis, in which case internalization is delayed. In some of these situations, or cases when exclusively external percutaneous biliary drains are placed due to inability to transverse the site of obstruction, having continued external drainage can be cumbersome and uncomfortable for patients. External drains can require significant maintenance, including emptying and flushing of the drain as well as routine drain exchange to prevent occlusion. It should also be noted that PTC can cause bacteremia, cholangitis and hemobilia. Internal-external and external biliary drains can also be prone to leakage, dislodgement and obstruction. However, in cases when ERCP fails these drains are an appropriate means of biliary decompression.

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Advantages And Disadvantages Of Stents

Advantages

  • The stent should open up the blocked bile duct and relieve the jaundice.
  • You should start feeling better quickly, normally within a couple of days of having the stent put in.
  • Treating the jaundice may mean you can start or continue treatment for the cancer.

Disadvantages

  • The stent may get blocked and the symptoms you had before may come back.
  • There is a chance of getting an infection after having a stent put in. Infections can be treated with antibiotics.
  • There is a small chance of your stent moving after it has been put in. If this happens it may need to be replaced.
  • The procedure to put the stent in can cause pancreatitis, which is inflammation of the pancreas.

Citation Doi & Article Data

What Type of Surgeon Treats Pancreatic, Liver, or Bile Duct Cancer?

Citation:DOI:Dr Jeremy JonesRevisions:see full revision historySystems:

This is a basic article for medical students and other non-radiologists

Malignant biliary tract obstruction represents a group of conditions that cause obstructive jaundice. While most examples are the result of pancreatic head cancers, other malignancies may be causative.

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Complications Of Surgery For Pancreatic Cancer

The most frequent early complications of surgery include infections in the abdomen, bleeding in the abdomen, leakage of bile and/or digestive juices from the rerouted bile and pancreatic ducts into the abdomen, inflammation of the bile ducts, and rapid emptying of the stomach . The most frequent late complications include: diabetes, diarrhea, and malnutrition.

Treating A Blocked Bile Duct

Putting a stent into the bile duct aims to clear the blockage. This means that bile can flow again into the bowel.

Having a stent put in is generally a simple procedure. You usually have this done during a type of endoscopy called an ERCP . In some cases, your doctor may put a stent in through your skin, using a long needle.

For both procedures, you don’t eat or drink for about 6 hours before you have the stent put in. This is to make sure that your stomach and the top part of your bowel are empty. You have a drug that makes you sleepy and relaxes you before the procedure. This is called a sedative.

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What Is Jaundice

Jaundice is when your skin and the whites of your eyes turn yellow. This happens when you get a build-up of bile in your body. Bile is a liquid which your liver makes to help you digest food. Sometimes, pancreatic cancer can block the tube which carries the bile. This tube is called the bile duct. If this tube gets blocked, the bile builds up and you may get jaundice. Read more about jaundice and pancreatic cancer.

What Is A Stent

Endoscopic Retrograde Cholangiopancreatogram, Gastroenterology

Stents are small tubes that are put into the bile duct. Pancreatic cancer can also block the duodenum, which is the first part of the small intestine. This causes sickness. A stent can be put into the duodenum to open it and treat the sickness. Read more about stents for the duodenum here.

Your symptoms should start to improve soon after having a stent put in.

  • You may have a stent put in to treat your jaundice if you cant have surgery to remove the cancer.
  • If you have jaundice and your cancer can be removed by surgery but you are not yet well enough to have the operation, you may have a stent put into the bile duct before the surgery.
  • If your cancer can be removed by surgery and you are well enough to have the operation straight away, the surgery will treat the jaundice.
  • You may have a stent put in to treat jaundice if you are to going to have chemotherapy before surgery.

There can be problems with a stent. For example, it can get blocked or move out of place. There is also a risk of getting an infection or an inflamed pancreas . But your doctor or nurse can treat these problems if they happen.

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