Current RMA Instruments:

Changes from Previous Instruments:

 ICD Coding:

• ICD-9-CM Codes: 156.0
• ICD-10-AM Codes: C23

Brief description:

This is a primary malignant neoplasm of the gallbladder. Primary in this context means that the neoplasm has arisen in the gallbladder and not travelled (metastasised) from a distant location.

Confirming the diagnosis:

To confirm the diagnosis there needs to histology of the gallbladder tumour. High resolution imaging may be suggestive but is not sufficient for diagnosis.

The condition does not need to be symptomatic.

The relevant medical specialist is a gastroenterologist, oncologist or general surgeon.

Additional diagnoses covered by these SOPs

• Adenocarcinoma of the gallbladder
• Squamous cell carcinoma of the gallbladder

Conditions not covered by these SOPs   

• Benign tumours of the gallbladder^#  
• Carcinoid tumour#
• Cholangiocarcinoma of the bile duct*     (Malignant neoplasm of bile duct)
• Hodgkin’s lymphoma*
• Malignant neoplasm of the ampulla of Vater*     (Malignant neoplasm of bile duct)
• Malignant neoplasm of the bile duct*
• Malignant neoplasm of the common bile duct*     (Malignant neoplasm of bile duct)
• Malignant neoplasm of the common hepatic duct*     (Malignant neoplasm of bile duct)
• Malignant neoplasm of the cystic duct*     (Malignant neoplasm of bile duct)
• Malignant neoplasm of the hepatic duct*     (Malignant neoplasm of bile duct)
• Non-Hodgkin’s lymphoma*
• Soft tissue sarcoma*

* another SOP applies  - the SOP has the same name unless otherwise specified

^# non-SOP condition

Clinical onset

The assessment of the clinical onset begins with the positive histopathology, then goes back in time to the date of positive imaging, and if possible goes back to the onset of clinical symptoms and signs which are consistent with the neoplastic process. The usual clinical presentation is painless jaundice, right upper quadrant abdominal pain and weight loss, with the jaundice being the most specific sign.

Note that gallbladder neoplasia may be silent, with the neoplasm discovered incidentally during some other investigation procedure. As such the clinical onset is the date of this incidental investigation, unless other overlooked chanracteristic symptoms or signs can take the clinical onset further back in time.

If the client suffers with biliary obstruction, then the clinical presentation of the biliary colic and obstructive jaundice will likely be the true clinical onset.

Clinical worsening

It is difficult to ascertain whether a malignant neoplasm has clinically worsened out of keeping with the natural history of the underlying pathology.

As such it is recommended that an opinion from an oncologist be sought, to provide an opinion on whether a clinical worsening is out of keeping with the natural history of the underlying pathology.