Skip to textbook content
Doctor’s PassportTextbook
TopicsAll topics

Loading topic navigation…

Textbook navigation
TopicsAll topics

Loading topic navigation…
Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Cholangiocarcinoma and gallbladder cancer

Oncology and palliative care · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
!
Acute cholangitis

Obstructed infected bile can progress quickly to septic shock and acute kidney injury.

Action: 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.

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.
  • MRI with MRCP refines the next decision because this is especially valuable for perihilar tumours and avoids losing key anatomical information after stent artefact or decompression.
  • Define anatomy before intervention: Obtain contrast CT and MRI/MRCP before stenting when feasible, then review ducts, vessels, lobar atrophy, future remnant and metastases in the hepatobiliary MDT.
  • Control infected or clinically important obstruction: Drain the infected and intended functional liver segments rather than maximising the number of stents without a map.
  • A major avoidable harm is recurrent cholangitis; Incomplete or occluded drainage allows infected bile to recur, causing sepsis and interrupting cancer treatment.
  • A common diagnostic trap is benign biliary stricture: Surgery, pancreatitis, ischaemia and inflammatory disease can narrow ducts; persistent or progressive stricture requires repeated specialist sampling.

Key red flags

Progressive jaundice, dark urine, pale stool and pruritus suggests extrahepatic biliary obstruction.

Fever, rigors, right-upper-quadrant pain, hypotension or confusion with jaundice indicates cholangitis.

A patient with primary sclerosing cholangitis develops worsening cholestasis, weight loss or a dominant stricture.

A gallbladder mass, suspicious polyp or unexpected carcinoma is reported after cholecystectomy.

Unexplained right-upper-quadrant pain, weight loss or liver mass persists without jaundice.

Cholangitis

Fever, rigors, pain, confusion or shock with obstruction requires emergency antibiotics and drainage.

Investigation priorities

01
Contrast CT chest, abdomen and pelvisFirst step

Define primary anatomy, vascular involvement, nodes, metastases and broad resectability.

Management branches

MapDefine anatomy before intervention

Biliary or gallbladder cancer is suspected and the patient is stable without uncontrolled cholangitis.

  1. Obtain contrast CT and MRI/MRCP before stenting when feasible, then review ducts, vessels, lobar atrophy, future remnant and metastases in the hepatobiliary MDT.
  2. Avoid a casual transperitoneal biopsy of a potentially transplant-eligible hilar lesion; select tissue route with the definitive pathway in mind.
  3. Assess liver reserve, performance, nutrition, infection, coagulation and operative fitness alongside anatomical stage.

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.Monitor counts, renal and liver function, magnesium, hearing, neuropathy, infection and hydration, plus immune pneumonitis, colitis, hepatitis and endocrinopathy; cisplatin fitness and biliary sepsis require review before each dose.
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.Confirm DPD status before fluoropyrimidine, review renal function, diarrhoea, mucositis, hand–foot syndrome and interactions, and stop urgently for severe early toxicity.
Open full textbook →Answer 2 questions
Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • British Society of Gastroenterology cholangiocarcinoma full guidelineUK recommendations for anatomical staging, biliary drainage, tissue, surgery and systemic treatment.
  • Royal College of Pathologists cancer datasetsUK pathology sampling, staging, margin and molecular reporting standards.
  • BNF durvalumab, gemcitabine, cisplatin, capecitabine and colestyramineUK prescribing, contraindication and monitoring information for durvalumab, gemcitabine, cisplatin, capecitabine and colestyramine.
  • NICE biliary tract cancer technology appraisalsCurrent NHS technology recommendations for systemic and targeted biliary cancer treatments.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom