What is Gall Bladder? Anatomy and Functions 
Gall bladder is a small pear shaped organ on the right side of abdomen, behind the right lower ribs, just below the liver. It usually measures about an inch in width and 3-4 inches long. The function of gall bladder is to concentrate and store digestive fluid called bile that is formed in the liver. During the process of digestion, when food enters the first part of the small intestine, the gall bladder contracts and releases bile into small intestine through a which helps in digesting the fats. Gall bladder is helpful organ but not an essential organ, one can live without it. Many people who have got their gall bladder removed lead normal life after surgery.
Gall bladder cancer (GBC) forms in the tissues of gall bladder.
Exact causes of gall bladder cancer are not known. There are several risk factors for GBC that increases the risk of gall bladder cancers.
(a) Pancreas and bile duct abnormalities- Some congenital abnormalities (present since birth) of the pancreas and bile ducts increase the risk of getting gall bladder cancer [17,8].
(b) Choledochal cysts- Congenital choledochal cysts are bile-filled sacs (dilatations) along the bile duct that are connected to the common bile duct, the tube that carries bile from the liver and gall bladder and empties into the duodenum, a part of the small the intestine . The cells lining these sacs often have areas of pre-cancerous changes, which increase a person’s risk for gall bladder cancer .
(a) Obesity- Being overweight can increase the risk of many types of cancers, including gall bladder cancer . The association of GC with overweight was the second strongest among all cancer sites after that of cancer of the corpus uteri among women and liver cancer among men. Obesity is in fact a risk factor for gallstones, which have a definite association with gall bladder cancer . It has been estimated that one out of ten cases of gall bladder cancer in men and almost a fifth of cases in women are linked with obesity .
(b) Infection -- Chronic infection with salmonella, the bacterium that cause typhoid, can cause gall bladder inflammation and this can increase the risk of gall bladder cancer in people who have gallstones [24,25]. Approximately 6% of carriers of Salmonella typhi developed gall bladder cancer and the association showed a 12-fold increase in risk for developing GBC . A few studies show that Helicobacter pylori bacteria may also increase the risk of gall bladder cancer [26,27].
(c) Diet -- Diet with increased quantities of proteins, fats and cholesterol and low in fibre, vegetables and fruits has been suggested as a risk factor for GBC . Though a few studies from India which also suggest association but lack scientific evidence at a population level, to prove the definite link between diet and GBC .
If you have one or more risk factors, it does not imply that you will get gall bladder cancer certainly. Many people with more or no exposure to risk factors also get cancer.
There is no sure way to prevent gall bladder cancers. We cannot modify risk factors such as age, gender, race, ethnicity and congenital abnormalities. But we can always take precautions to reduce the risk. Obesity is one of the important risk factor. It is always recommended to maintain healthy weight and lead an active life.
Healthy diet with cereals, whole grains instead of refined, at least two and half cups of fruits and vegetables daily, limiting intake of processed food and red meat have been shown to lower the risk of many cancers including GBC.
If the gall stones cause any problems that may warrant removal of gall bladder, it should be removed in consultation with the treating doctor.
Signs and Symptoms
Gall bladder cancer usually does not produce signs or symptoms in its early stages, but in late stages it presents with a number of symptoms. By the time your doctor diagnoses GBC, it may be at an advanced stage, where treatment options are limited. Many early stage gall bladder cancers are chance findings, when the patient comes for some other reason.
Other illnesses apart from gall bladder cancer can also cause symptoms similar to those produced by gall bladder cancer. However, it is important to consult a doctor and get yourself thoroughly examined and investigated to exclude GB pathology.
Common symptoms of gall bladder cancer:
Abdominal pain: Most people with gall bladder cancer have an aching feeling on the upper right part of the tummy. One may feel a sharper pain if the gall stones or cancer block the bile duct.
Nausea and/or vomiting:
Jaundice: Fifty per cent of the people diagnosed with gall bladder cancer have jaundice .
Jaundice is a yellowing of the skin and the white part of the eyes. Jaundice is due to the accumulation of a bile salt called bilirubin (a chemical that gives bile its yellow colour) in the blood . If the cancer grows large enough to block the bile ducts, bile from the liver can’t drain into the intestines. This can cause build-up of bilirubin in the blood and body tissues causing jaundice . It may produce symptoms like severe itching, darkened urine, or pale coloured stools.
Having jaundice does not always imply that you have gall bladder cancer. A much more common cause of jaundice is a viral infection of the liver (hepatitis). However, if it is due to GBC, it indicates an advanced stage of cancer.
Lump in the abdomen: If the cancer growth blocks the bile ducts, the gall bladder may swell much larger than its normal size and may present as a lump in the right side of the tummy.
Other symptoms: Less common symptoms of gall bladder cancer includes loss of appetite, fever, weight loss.
Gall bladder cancer is not common in all parts of India [6,8]. The symptoms and signs similar to the ones produced by GBC are more likely to be caused by some other more common conditions. For example, people with gallstones also have many of these symptoms. Yet, if you have any of these symptoms, it’s important to consult doctor without delay neglect so that the cause can be found and treated, if needed.
Fine needle aspiration biopsy/cytology (FNAB/FNAC): a very thin needle attached to a syringe is used to aspirate a sample of cells without using anesthesia.
FNAC is not indicated in resectable GBC because the tumor has propensity for seeding the biopsy tracts and resection should be performed even if FNAC is negative. However, if there is clinical evidence of distant metastatic disease (e.g. left supraclavicular lymph node, umbilical nodule, liver nodule, pelvic deposits or ascites) a tissue diagnosis should be obtained (FNAC, fluid cytology) from the metastasis. A few centers use Endoscopic ultrasound-guided FNAC in suspicious gallbladder lesions and has been reported to have sensitivity rate of 80% and specificity of up to 100% .
Core needle biopsy: A larger, hollow needle is inserted into the mass and cylindrical piece of tissue (core) is taken out for histopathological examination to confirm cancer. A core biopsy provides more tissue for examination than FNA.
If the surgeon is planning for removal of gallbladder tumour, then it is not always necessary to have a biopsy report.
In a Jaundiced patient:
a. Coagulation profile (prothrombin time, etc.)
b. Magnetic Resonance CholangioPancreaticography (MRCP)
c. Endoscopic Retrograde CholangioPancreaticography (ERCP)/Percutaneous Transhepatic Cholangiography (PTC) if a therapeutic intervention (biliary stenting) is planned
d. Informed Consent for Extended Cholecystectomy (EC)
- Positron Emission Tomography (PET) scan
- Tumor markers: Serum Ca 19-9, CEA are not very specific in the diagnosis of gall bladder cancer. But their rise may add to the diagnosis 
Primary tumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
T1 Tumor invades lamina propria or muscular layer
T1a Tumor invades lamina propria
T1b Tumor invades muscular layer
T2 Tumor invades perimuscular connective tissue; no extension beyond serosa or into liver
T3 Tumor perforates the serosa (visceral peritoneum) and/or directly invades the liver and/or one other adjacent organ or structure, such as the stomach, duodenum, colon, pancreas, omentum or extrahepatic bile ducts
T4 Tumor invades main portal vein or hepatic artery or invades two or more extrahepatic organs or structures
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastases to nodes along the cystic duct, common bile duct, hepatic artery and/or portal vein
N2 Metastases to periaortic, pericaval,superior mesenteric artery and/or celiac artery lymph nodes
Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage IIIA T3 N0 M0
Stage IIIB T1–3 N1 M0
Stage IVA T4 N0–1 M0
Stage IVB Any T N2 M0
Any T Any N M1
Histological Grade (G)
GX Grade cannot be assessed
G1 Well differentiated
G2 Moderately differentiated
G3 Poorly differentiated
For more information please visit http://www.icmr.nic.in/guide/cancer/Gall%20Bladder/GALLBLADDER%20CANCER.pdf
A. Resectable GBC [pT1-3 (Selected T4), N0-1, M0]
(Medically fit patients)
pT1a* - Simple Cholecystectomy (with negative cystic duct margin)
pT1b, pT2† - Extended Cholecystectomy (enbloc wedge resection/segment
IVb+V resection of the liver + LND#) + CBD resection
pT3, pT4**#† - Enbloc hepatic resection + cholecystectomy
*It is very difficult to diagnose pT1, pT2 GBC preoperatively. It is usually diagnosed upon HPE of the cholecystectomy specimen. Relaparotomy and hepatic resection+ LND ±CBD resection is indicated in pT1b and above incidental GBC.
It is advisable to open every cholecystectomy gallbladder specimen to look for any suspicious mass lesion/thickening and intraoperative frozen section if facilities and the necessary expertise are available.
pT2 and above (following complete tumor resection):
B. Metastatic /Unresectable GBC
May be used for relief of pain in selected patients
•• for relief of jaundice and pruritis – ERCP and stenting (metallic/plastic stent)
•• for pain relief - Medicines as per the WHO step-ladder or celiac plexus block in refractory cases
•• for relief of gastric outlet obstruction - Gastrojejunostomy in patients with good performance status
Only in context of a clinical trial
Every 6 months for 2 years
There is no robust data to support aggressive surveillance post resection. Patients may be followed up by imaging. Re-staging according to initial workup should be considered in the event of disease relapse or progression.
For detailed treatment protocols, please refer to the pdf.
 http://pathology2.jhu.edu/bileduct/anatphys.cfm accessed on April 17, 2015.
 www.cancer.gov accessed on April 17, 2015.
 Ferlay J, Soerjomataram I, Ervik M, et al. (2013) GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC Cancer Base No. 11.Lyon, France: http://globocan.iarc.fr. Accessed on 22 April 2015.
 Albores-Saavedra, J, Menck, HR, Scoazec JC, et al. Chapter 9. Carcinoma of the gallbladder and extrahepatic bile ducts. in: S.R. Hamilton, L.A. Altonen (Eds.) Pathology and genetics of tumours of the digestive system. IARC Press, Lyon; 2000;206–213. www.iarc.fr/en/publications/pdfs-online/pat-gen/bb2/bb2-chap9.pdf accessed on 19th April 2015.
 Parkin DM, Whelan SL, Ferlay J, et al. Cancer in Five continents. 1997; Vol. VII: Lyon: International Agency for Research on Cancer, 1007.
 National Cancer Registry Program Report. http://www.icmr.nic.in/ncrp/PBCR_Report%202009_2011. Accessed on 22 April 2015.
 Nandakumar A, Gupta PC, Gangadharan P, et al. Geographic pathology revisited: Development of an atlas of cancer in India. Int J Cancer 2005; 116: 740–754 .
 Dhir V and Mohandas KM. Epidemiology of digestive tract cancers in India: IV Gall bladder and pancreas. Indian J Gastroenterol 1999;18: 24-28.
 Shaffer EA. Gallbladder Cancer - The Basics Gastroenterol Hepatol (N Y) 2008; 4(10): 737–741.
 Misra S, Chaturvedi A, Misra NC, et al. Carcinoma of the gallbladder. Lancet Oncol 2003;4:167-176.
 Shaffer EA. Gallstone disease: epidemiology of gallbladder stone disease. Best Pract Res Clin Gastroenterol 2006;20:981-996.
 Randi G, Franceschi S and Vecchia CL. Gallbladder cancer worldwide: Geographical distribution and risk factors. Int J Cancer 2006; 118: 1591–1602.
 Mohan H, Punia RPS , Dhawan SB, et al Morphological spectrum of gallstone disease in 1100 cholecystectomies in North India. Ind J Surg 2005; 67: 140-2.
 Marks JM and Ponsky JL. Malignant gall bladder tumours. In: DiMarino AJ Jr and Benjamin SB Eds Gastrointestinal Disease: an Endoscopic Approach. Massachuetts: Blackwell Science. 1007: 843-51.
 Stinton LM and Shaffer EA. Epidemiology of Gallbladder Disease: Cholelithiasis and Cancer. Gut Liver 2012; 6(2): 172–187.
 Unisa S, Jagannath P, Dhir V, et al. Population-based study to estimate prevalence and determine risk factors of gallbladder diseases in the rural Gangetic basin of North India. HPB 2011; 13: 117–125.
 http://pathology2.jhu.edu/bileduct/symptoms.cfm accessed on 25th April, 2015.
 Chang LY, Wang HP, Wu MS, et al. Anomalous pancreaticobiliary ductal union—an etiologic association of gallbladder cancer and adenomyomatosis. Hepatogastroenterology 1998;45: 2016- 2019.
 Myers RP, Shaffer EA and Beck PL. Gallbladder polyps: epidemiology, natural history and management. Can J Gastroenterol 2002;16:187-194.
 www.cancerresearchuk.org accessed on 24th April 2015.
 Fernandez E, La Vecchia C, D'Avanzo B, et al. Family history and the risk of liver, gallbladder, and pancreatic cancer. Cancer Epidemiol Biomarkers Prev 1994; 3:209–212.
 Pandey SN, Srivastava A, Dixit M, et al. Haplotype analysis of signal peptide (insertion/deletion) and XbaI polymorphisms of the APOB gene in gallbladder cancer. Liver Int 2007;27:1008-1015.
 Stender S, Nordestgaard BG, Tybjaerg-Hansen A, et al . Elevated body mass index as a causal risk factor for symptomatic gallstone disease: a Mendelian randomization study. Hepatology 2013; 58(6):2133-41.
 Caygill CP, Hill MJ, Braddick M, et al. Cancer mortality in chronic typhoid and paratyphoid carriers. Lancet 1994; 343(8889):83-4.
 Dutta U, Garg PK, Kumar R, et al. Typhoid carriers among patients with gallstones are at increased risk for carcinoma of the gallbladder. Am J Gastroenterol 2000; 95(3):784-7.
 Kumar S, Kumar S, Kumar S. Infection as a risk factor for gallbladder cancer. J Surg Oncol 2006;93:633-639.
 Bulajic M, Maisonneuve P, Schneider-Brachert W, et al. Helicobacter pylori and the risk of benign and malignant biliary tract disease. Cancer 2002;95:1946 –53.
 Shebl FM, Andreotti G, Rashid A, et al. Diabetes in relation to biliary tract cancer and stones: a population-based study in Shanghai, China. Br J Cancer 2010; 103(1):115-9.
 Pandey M , Shukla M and Shukla V. Diet and Gallbladder Cancer. Editorial-II Indian Journal of Medical & Paediatric Oncology 2008; Vol. 29 No 1, 6.
 Sheth S, Bedford A and Chopra S. Primary gallbladder cancer: recognition of risk factors and the role of prophylactic cholecystectomy. Am J Gastroenterol 2000; 95(6):1402-10.
 Chijiiwa K, Sumiyoshi K, Nakayama F. Impact of recent advances in hepatobiliary imaging techniques on the preoperative diagnosis of carcinoma of the gallbladder. World J Surg 1991, 15: 332-337.
 Kim JH, Kim TK, Eun HW, et al. Preoperative evaluation of gallbladder carcinoma: Efficacy of combineduse of MR imaging, MR cholangiography, and contrast-enhanced dual-phase three dimensional MR angiography. J Magn Reson Imaging 2002; 16: 676–684.
 Meera RS, Jhala D, Eloubeidi MA, et al. Endoscopic ultrasound-guided FNA biopsy of the bile duct and gallbladder: analysis of 53 cases. Cytopathology 2006; 17(1):42-49.
 Bartlett DL, Fong Y. Tumors or the gallbladder. In: Blumgart LH, Fong Y, editors: Surgery of the liver and biliary tract. 3rd edition. London: WB Saunders; 2000. 993-1015.