Synopsis
Classify suspected cholangiocarcinoma by anatomical site, protect staging and tissue strategy, manage obstruction safely and route treatment through a specialist hepatobiliary multidisciplinary team.
- Classify cholangiocarcinoma as intrahepatic, perihilar or distal because symptoms, imaging, tissue route, drainage, surgery and molecular patterns differ materially by site.
- Extrahepatic disease commonly presents with progressive jaundice, dark urine, pale stool and pruritus; intrahepatic tumours may present as a liver mass, pain, weight loss or incidental imaging abnormality.
- Primary sclerosing cholangitis, choledochal cysts and selected chronic biliary inflammatory disorders increase risk, but most patients do not have an obvious pre-existing syndrome.
Key red flags
Fever, rigors, hypotension or confusion with malignant jaundice indicates cholangitis and requires emergency sepsis treatment plus appropriately planned biliary decompression.
Investigation priorities
Stage every suspected CCA, define primary extent and vascular relations, and identify nodal or distant spread.
Management branches
Imaging, jaundice or a dominant stricture raises a credible suspicion of cholangiocarcinoma without emergency sepsis.
- Classify the likely site, review benign alternatives and send liver, renal, clotting and inflammatory blood tests with a careful biliary history.
- Obtain multiphasic CT of chest, abdomen and pelvis, adding contrast MRI and MRCP for proximal or intrahepatic anatomy before endoscopy.
Key medicines
Capecitabine after resectionUse only the current specialist adjuvant protocol, typically delivered over a defined course with body-surface-area calculation and cycle review.
First-line advanced biliary cancer regimenDeliver a nationally commissioned oncology protocol such as gemcitabine-platinum with any approved immunotherapy component, using current cycle-specific prescribing.