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SMALL BOWEL

SMALL BOWEL. TUMORS. CLASIFICATION Origin : Benign Malign ant Epiteliu m adenom a adenocarcinom a E nterocroma ph ine cells - carcinoid C onjunctiv: fibrom a fibrosarcom a V ascular: hemangiom a angiosarcom a

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SMALL BOWEL

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  1. SMALL BOWEL

  2. TUMORS • CLASIFICATION • Origin : Benign Malignant • Epitelium adenoma adenocarcinoma • Enterocromaphine cells - carcinoid • Conjunctiv: fibroma fibrosarcoma • Vascular: hemangioma angiosarcoma • lymfangioma - • Lymphoid - limphoma • Smooth muscle leiomioma, GIST leiomiosarcoma GIST • Nervi and nerve sheat neurofibroma neurofibrosarcoma • neurinoma schwannoma malignant • Adipocite lipoma liposarcoma • Others sdr Peutz-Jeghers metastatic tumors • melanoma malign

  3. TUMORS • Risk factors • FAP, Crohn, CCNPE, Peutz-Jagers, ABD • Controversial • Smoking, alcohol (>80g/days), read meat, salty food • TB • GIST • Adenoama • True simple adenoma, vilos adenoma, Brunner gland adenoma • Malignant potential!!!! • Lipoma • Hamartoama • Sdr Peutz-Jagers • Malignant potential • TM • Adenocarcinoma– 50% • Carcinoid • GIST • limphoma

  4. SYMPTOMS • Depend on location and relation to the bowel lumen • Localization • 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 • endolumenal – intestinal obstruction through: • obstruction • Intermitent invagination • Intramural – may favor invagination but also volvulus

  5. TUMORI INTESTIN SUBŢIRE • Clinical diagnosticmay be suggested by: • Dispeptic symptoms • Non-characteristic; • Abdominal pain: non precise, diffuse, intermitent • Alternation of diarhea and constipation • Recurrent incomplete obstruction • Colicky abdominal pain in the mesogastrum; • Palpable distended bowe loop; • Borborism, najor emission of flatus and feaces (sdr. Kőnig). • GI bleeding • Ocult bleeding or melena + aneamia • Palpable tumor • 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

  6. Paraclinical examination • 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)

  7. Radiology: • Plain X Ray: • 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 • Filing defect: • circular • Well circumscribed; • Mucosal margin clear • Stenosis: • Regular margins; • Clear mucosal margins; • Normal persitalsis of the bowel • Invagination: • jejuno-jejunal; • ileo-ileal; • ileo-colic.

  8. TUMORS • Malignant tumors • Filing defect • irregular • Cmucosal layer discontinuos • Stenosis: • 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

  9. EXPLORATION • Ultrasound • Structure: solid, cystic, • Position • Dimension • Can detect • invagination; • Stasis above a tumor; • Regional LN; • Ascitis. • Can show liver MTS; • Biopsy guided on US • CT

  10. EXPLORATION • Arteriography • Most beneficial in cases of bleeding – contrast pooling near lesion • Can show the tumor in highly vascular tumors : • Hemangioama; • Hemangiosarcoama. • Beneficial in low vascular tumors – adenocarcinoma (disruption of normal vasculature). • Endoscopy – enteroscopy: • Unusual - difficult • SDifferent techniques – all the bowel can be visualized • Laparoscopy, laparotomy

  11. COMPLICATIONS • Intestinal obstruction • Mechanism: • Obstruction; • Invagination; • Volvulus; • Alimentary bolus impaction or foreign body – partila stenosis produced by the tumor; • Perforation • Mechanism: • necrosisand ulceration of the tumor; • Diastatic – dilated loop above stenosis • Tumor infection • Haemorhagy • Spontaneous rupture of the pedicle: – tumor destruction + bleeding important

  12. TREATMENT A. Surgical • Benign tumors: • Small: enterotomy + enucleation + eneroraphy • Big: segmental enetrectomy. • Malignant tumors: • 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 • Lymphomas are sensitive • C. Chemotherapy • Not very good in adenocarcinoma • Lymphoma tend to do better, at least at the begining.

  13. 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: • Facila flush; • GI hypermotility; • Hepatomegaly; • Bronchospasm • Right heart valvular lesions (endocardum nodules). • 5-HIAA detection in the blood ;

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