SMALL BOWEL SMALL BOWEL

TUMORSTUMORS CLASIFICATIONCLASIFICATION

Origin Origin : : Benign Benign MalignMalignantant

EpiteliuEpiteliumm adenomadenomaa adenocarcinomadenocarcinomaa

EEnterocromanterocromaphphineine cells cells - - carcinoidcarcinoid

CConjunctiv:onjunctiv: fibromfibromaa fibrosarcomfibrosarcomaa

VVascular:ascular: hemangiomhemangiomaa angiosarcom angiosarcomaa llyymfangiommfangiomaa - - LyLymmphphoidoid - - limlimphphomomaa Smooth muscleSmooth muscle leiomiom leiomioma,a, GIST GIST

leiomiosarcomleiomiosarcomaa GIST GIST NerviNervi and nerve sheat and nerve sheat neurofibrom neurofibromaa

neurofibrosarcomneurofibrosarcomaa neurinomneurinomaa schwannom schwannomaa

malignmalignantant AdipociteAdipocite lipom lipomaa liposarcomliposarcomaa OthersOthers sdr Peutz-Jeghers sdr Peutz-Jeghers metastatic metastatic tumors tumors melanommelanomaa malign malign

TUMORSTUMORS Risk factorsRisk factors

FAP, Crohn, CCNPE, Peutz-Jagers, ABDFAP, Crohn, CCNPE, Peutz-Jagers, ABD ControversControversialial

Smoking, alcoholSmoking, alcohol (>80g/ (>80g/daysdays), ), read meat, salty foodread meat, salty food TB TB

GISTGIST AdenoamAdenoamaa

True simple adenomaTrue simple adenoma, vilos, vilos adenoma adenoma, Brunner, Brunner gland adenoma gland adenoma Malignant potential!!!!Malignant potential!!!!

LipoLipomama HamartoamHamartoamaa

Sdr Peutz-JagersSdr Peutz-Jagers Malignant potentialMalignant potential

TMTM AdenocarcinomAdenocarcinomaa– 50%– 50% CarcinoidCarcinoid GISTGIST limlimphphomomaa

SYMPTOMSSYMPTOMS Depend on location and relation to the Depend on location and relation to the

bowel lumenbowel lumen LocalizationLocalization

Very high positioned tumors (jejunal) – symptoms Very high positioned tumors (jejunal) – symptoms very similar with distal duodenal stenosis very similar with distal duodenal stenosis

Ileal tumors – later symptoms (related to food Ileal tumors – later symptoms (related to food ingestion) – may be similar with apendicitis crisisingestion) – may be similar with apendicitis crisis

According to type of development According to type of development endolumenal – endolumenal – intestinal obstruction throughintestinal obstruction through: :

obstrucobstructiontion Intermitent invaginationIntermitent invagination

Intramural – may favor invagination but also Intramural – may favor invagination but also volvulusvolvulus

TUMORI INTESTIN TUMORI INTESTIN SUBSUBŢIREŢIRE Clinical diagnosticClinical diagnostic may be suggested by:may be suggested by:

DispepticDispeptic symptoms symptoms Non-characteristicNon-characteristic;; Abdominal pain: non precise, diffuse, intermitentAbdominal pain: non precise, diffuse, intermitent Alternation of diarhea and constipationAlternation of diarhea and constipation

Recurrent incomplete obstructionRecurrent incomplete obstruction ColiColicky abdominal pain in the mesogastrumcky abdominal pain in the mesogastrum;; Palpable distended bowe loopPalpable distended bowe loop;; BBorborism, orborism, najor emission of flatus and feaces (najor emission of flatus and feaces (sdr. Kőnig).sdr. Kőnig).

GI bleedingGI bleeding OcultOcult bleeding or bleeding or melen melena + aneamia a + aneamia

Palpable tumorPalpable tumor Unusual: mobile or fix (Unusual: mobile or fix (adeadesionssions);); Same area as the borborism or colicky painSame area as the borborism or colicky pain Sometimes palpable through vagina or recta touchSometimes palpable through vagina or recta touch; ; Vanishing tumor: may be produced by invaginationVanishing tumor: may be produced by invagination

Paraclinical examinationParaclinical examination

LaLab:b: Aneamia, microcytic, hyochromicAneamia, microcytic, hyochromic;; Increased ESRIncreased ESR;; AdlerAdler test test pozitiv pozitiv (occult bleeding) (occult bleeding);; ACE ACE andand ά fetoprotena ά fetoprotena: may be increased : may be increased

but non often and not importantbut non often and not important acid 5-hidroindolacetic (5-HIAA) acid 5-hidroindolacetic (5-HIAA) may be may be

rised in carcinoid tumors (metastatic rised in carcinoid tumors (metastatic disease – high values)disease – high values)

RadiologRadiologyy:: Plain X RayPlain X Ray::

OcluOclusion: sion: hidroaerichidroaeric levels on levels on the small bowelthe small bowel;;

Meteorism (incomplete Meteorism (incomplete obstruction)obstruction);;

Barium follow upBarium follow up:: Better for high positioned Better for high positioned

tumorstumors Barium enema for distal ileumBarium enema for distal ileum;; EEnteroclinteroclissis- is- better results for better results for

small bowelsmall bowel.. BENIGN TUMORSBENIGN TUMORS

Filing defectFiling defect:: circularcircular Well circumscribedWell circumscribed;; Mucosal margin clearMucosal margin clear

StenoStenosissis:: Regular marginsRegular margins;; Clear mucosal marginsClear mucosal margins;; Normal persitalsis of the bowelNormal persitalsis of the bowel

InvaginaInvaginationtion:: jejuno-jejunal;jejuno-jejunal; ileo-ileal;ileo-ileal; ileo-colic.ileo-colic.

TUMORSTUMORS Malignant tumorsMalignant tumors

Filing defectFiling defect irregularirregular CCmucosal layer mucosal layer

discontinuosdiscontinuos StenoStenosissis::

Irregular bordersIrregular borders;; Wall invasionWall invasion..

DilationDilation Indirect signsIndirect signs Small bowel loops Small bowel loops

adjacent to a tumor with adjacent to a tumor with dilated loops above the dilated loops above the tumortumor

Bowel loops pushed Bowel loops pushed against a region of the against a region of the abdomen – displacement abdomen – displacement

EXPLORATIONEXPLORATION UltrasoundUltrasound

Structure: solid, Structure: solid, cystic,cystic,

PositionPosition DimensionDimension

Can detectCan detect invaginainvaginationtion;; StaStasis above a tumorsis above a tumor;; Regional LNRegional LN;; AscitisAscitis..

Can show liver MTSCan show liver MTS;; Biopsy guided on USBiopsy guided on US

CTCT

EXPLORATIONEXPLORATION ArteriogArteriographyraphy

Most beneficial in cases of Most beneficial in cases of bleedingbleeding – – contrast pooling contrast pooling near lesionnear lesion

Can show the tumor in Can show the tumor in highly vascular tumors highly vascular tumors ::

HemangioamHemangioamaa;; HemangiosarcoamHemangiosarcoamaa..

Beneficial in low vascular Beneficial in low vascular tumorstumors – adenocarcinom – adenocarcinomaa ((disruption of normal disruption of normal vasculaturevasculature).).

EndoscopEndoscopyy – – enteroscopenteroscopyy:: Unusual - difficultUnusual - difficult SSDifferent techniques – all Different techniques – all

the bowel can be visualizedthe bowel can be visualized LaparoscopLaparoscopyy, ,

laparotomlaparotomyy

COMPLICATIONSCOMPLICATIONS Intestinal obstructionIntestinal obstruction

MecMechhanism:anism: ObstrucObstructiontion;; InvaginaInvaginationtion;; VVolvulus;olvulus; Alimentary bolus impaction or foreign body – partila Alimentary bolus impaction or foreign body – partila

stenosis produced by the tumorstenosis produced by the tumor;;

PerforaPerforationtion MecMechhanism:anism:

necronecrosissis andand ulcera ulceration of the tumortion of the tumor;; DiastaticDiastatic – dilated loop above stenosis – dilated loop above stenosis Tumor infectionTumor infection

HHaaemoremorhhagagyy Spontaneous rupture of the pedicle: Spontaneous rupture of the pedicle: ––

tumor destruction + bleeding importanttumor destruction + bleeding important

TREATMENTTREATMENTA. A. SurgicalSurgical

BBenignenign tumors tumors:: Small: enterotomy + enucleation + eneroraphy Small: enterotomy + enucleation + eneroraphy Big: segmental enetrectomyBig: segmental enetrectomy..

Malignant tumors:Malignant tumors: Segmental eSegmental enterecomnterecomyy with security margins + LN with security margins + LN

clearing: dubtful – radicality is often impossible due to clearing: dubtful – radicality is often impossible due to unlimited LN teritory. And rapid spread in the LN in unlimited LN teritory. And rapid spread in the LN in the paraaortic and retropancreatic regions the paraaortic and retropancreatic regions ;;

Distal ileum: right colectomy Distal ileum: right colectomy ;; Paleation: resections / by passPaleation: resections / by pass..

B. RadiotB. Radiothheraperapyy Lymphomas are sensitiveLymphomas are sensitive

C. ChC. Cheemotmothheraperapyy Not very good in adenocarcinomaNot very good in adenocarcinoma Lymphoma tend to do better, at least at the beginingLymphoma tend to do better, at least at the begining..

CARCINOID TUMORSCARCINOID TUMORS Small bowell – 2Small bowell – 2ndnd after apendix after apendix More often - ileumMore often - ileum SSerotonine excretionerotonine excretion Often small single tumor, yellow on Often small single tumor, yellow on

section, developed in submucosa section, developed in submucosa Histologically bening BUT may Histologically bening BUT may

have malignant behavior including have malignant behavior including MTS MTS

Symptoms: identical with small Symptoms: identical with small bowel tumors + CARCINOID bowel tumors + CARCINOID SYNDROME:SYNDROME:

Facila Facila flusflushh;; GI hypermotilityGI hypermotility;; HHepatomegalepatomegalyy;; Bronchospasm Bronchospasm Right heart valvular lesions (endocardum Right heart valvular lesions (endocardum

nodules)nodules).. 5-HIAA5-HIAA detection in the blood detection in the blood ;;