Transcript PATOLOGIE INTESTIN SUBTIRE

SMALL BOWEL
TUMORS
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CLASIFICATION
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Origin :
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Epitelium
Enterocromaphine cells
Conjunctiv:
Vascular:
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Lymphoid
Smooth muscle
Nervi and nerve sheat
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Adipocite
Others
Benign
adenoma
fibroma
hemangioma
lymfangioma
leiomioma, GIST
neurofibroma
neurinoma
lipoma
sdr Peutz-Jeghers
Malignant
adenocarcinoma
carcinoid
fibrosarcoma
angiosarcoma
limphoma
leiomiosarcoma GIST
neurofibrosarcoma
schwannoma malignant
liposarcoma
metastatic tumors
melanoma malign
TUMORS
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Risk factors
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FAP, Crohn, CCNPE, Peutz-Jagers, ABD
Controversial
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TB
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GIST
Adenoama
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True simple adenoma, vilos adenoma, Brunner gland adenoma
Malignant potential!!!!
Lipoma
Hamartoama
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Smoking, alcohol (>80g/days), read meat, salty food
Sdr Peutz-Jagers
Malignant potential
TM
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Adenocarcinoma– 50%
Carcinoid
GIST
limphoma
SYMPTOMS
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Depend on location and relation to the bowel
lumen
Localization
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Very high positioned tumors (jejunal) – symptoms very
similar with distal duodenal stenosis
Ileal tumors – later symptoms (related to food ingestion) –
may be similar with apendicitis crisis
According to type of development
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endolumenal – intestinal obstruction through:
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obstruction
Intermitent invagination
Intramural – may favor invagination but also volvulus
TUMORI INTESTIN SUBŢIRE
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Clinical diagnostic may be suggested by:
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Dispeptic symptoms
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Recurrent incomplete obstruction
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Colicky abdominal pain in the mesogastrum;
Palpable distended bowe loop;
Borborism, najor emission of flatus and feaces (sdr. Kőnig).
GI bleeding
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Non-characteristic;
Abdominal pain: non precise, diffuse, intermitent
Alternation of diarhea and constipation
Ocult bleeding or melena + aneamia
Palpable tumor
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Unusual: mobile or fix (adesions);
Same area as the borborism or colicky pain
Sometimes palpable through vagina or recta touch;
Vanishing tumor: may be produced by invagination
Paraclinical examination
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Lab:
Aneamia, microcytic, hyochromic;
 Increased ESR;
 Adler test pozitiv (occult bleeding);
 ACE and ά fetoprotena: may be increased but non
often and not important
 acid 5-hidroindolacetic (5-HIAA) may be rised in
carcinoid tumors (metastatic disease – high values)
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Radiology:
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Plain X Ray:
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Oclusion: hidroaeric levels on the small
bowel;
Meteorism (incomplete obstruction);
Barium follow up:
Better for high positioned tumors
Barium enema for distal ileum;
Enteroclisis- better results for small
bowel.
BENIGN TUMORS
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Filing defect:
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Stenosis:
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circular
Well circumscribed;
Mucosal margin clear
Regular margins;
Clear mucosal margins;
Normal persitalsis of the bowel
Invagination:
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jejuno-jejunal;
ileo-ileal;
ileo-colic.
TUMORS
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Malignant tumors
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Filing defect
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Stenosis:
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irregular
Cmucosal layer discontinuos
Irregular borders;
Wall invasion.
Dilation
Indirect signs
Small bowel loops adjacent to
a tumor with dilated loops
above the tumor
Bowel loops pushed against a
region of the abdomen –
displacement
EXPLORATION
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Ultrasound
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Structure: solid, cystic,
Position
Dimension
Can detect
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Can show liver MTS;
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invagination;
Stasis above a tumor;
Regional LN;
Ascitis.
Biopsy guided on US
CT
EXPLORATION
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Arteriography
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Most beneficial in cases of bleeding
– contrast pooling near lesion
Can show the tumor in highly
vascular tumors :
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Beneficial in low vascular tumors –
adenocarcinoma (disruption of
normal vasculature).
Endoscopy – enteroscopy:
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Hemangioama;
Hemangiosarcoama.
Unusual - difficult
SDifferent techniques – all the
bowel can be visualized
Laparoscopy, laparotomy
COMPLICATIONS
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Intestinal obstruction
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Mechanism:
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Perforation
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Mechanism:
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Obstruction;
Invagination;
Volvulus;
Alimentary bolus impaction or foreign body – partila stenosis produced by the
tumor;
necrosis and ulceration of the tumor;
Diastatic – dilated loop above stenosis
Tumor infection
Haemorhagy
Spontaneous rupture of the pedicle: – tumor destruction +
bleeding important
A. Surgical
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Benign tumors:
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Segmental enterecomy with security margins + LN clearing: dubtful –
radicality is often impossible due to unlimited LN teritory. And rapid
spread in the LN in the paraaortic and retropancreatic regions ;
Distal ileum: right colectomy ;
Paleation: resections / by pass.
B. Radiotherapy
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Small: enterotomy + enucleation + eneroraphy
Big: segmental enetrectomy.
Malignant tumors:
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TREATMENT
Lymphomas are sensitive
C. Chemotherapy
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Not very good in adenocarcinoma
Lymphoma tend to do better, at least at the begining.
CARCINOID TUMORS
 Small bowell – 2nd after apendix
 More often - ileum
 Serotonine excretion
 Often small single tumor, yellow on
section, developed in submucosa
 Histologically bening BUT may have
malignant behavior including MTS
 Symptoms: identical with small bowel
tumors + CARCINOID SYNDROME:
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Facila flush;
GI hypermotility;
Hepatomegaly;
Bronchospasm
Right heart valvular lesions (endocardum
nodules).
5-HIAA detection in the blood ;