Synopsis
Differentiate intrahepatic, perihilar, distal bile-duct and gallbladder cancers, control cholangitis, obtain adequate staging and tissue by a surgically safe route and coordinate resection, drainage and biomarker-directed systemic care.
- Painless cholestatic jaundice is a pivotal clue in Cholangiocarcinoma and gallbladder cancer: Extrahepatic obstruction causes jaundice, pruritus, dark urine and pale stool, often before a mass is palpable.
- Immediate priority in unstable Cholangiocarcinoma and gallbladder cancer: Use sepsis care, take cultures, give intravenous antibiotics and arrange urgent endoscopic or percutaneous biliary drainage with hepatobiliary expertise, selecting ducts deliberately in perihilar obstruction.
- Contrast CT chest, abdomen and pelvis is used early to define primary anatomy, vascular involvement, nodes, metastases and broad resectability. Use before unplanned drainage or biopsy where stable; perihilar disease needs expert review of future liver remnant and ductal anatomy.
Key red flags
Progressive jaundice, dark urine, pale stool and pruritus suggests extrahepatic biliary obstruction.
Fever, rigors, pain, confusion or shock with obstruction requires emergency antibiotics and drainage.
Investigation priorities
Define primary anatomy, vascular involvement, nodes, metastases and broad resectability.
Management branches
Biliary or gallbladder cancer is suspected and the patient is stable without uncontrolled cholangitis.
- Obtain contrast CT and MRI/MRCP before stenting when feasible, then review ducts, vessels, lobar atrophy, future remnant and metastases in the hepatobiliary MDT.
- Avoid a casual transperitoneal biopsy of a potentially transplant-eligible hilar lesion; select tissue route with the definitive pathway in mind.
Key medicines
Durvalumab with gemcitabine and cisplatinA licensed first-line schedule uses durvalumab 1,500 mg IV day 1 plus gemcitabine 1,000 mg/m² and cisplatin 25 mg/m² IV on days 1 and 8 every 21 days for up to 8 cycles, then durvalumab 1,500 mg every 4 weeks.
Capecitabine after resectionOn each 21-day adjuvant cycle, give capecitabine 1,250 mg/m² orally morning and evening on days 1 through 14, for 8 cycles with protocol-led adjustment and lower starting doses where clinically indicated.