Small bowel tumor

Introduction to small bowel tumors Small intestine tumor refers to the tumor that occurs in the small intestine from the duodenum to the ileocecal valve. The small intestine tumor described in this chapter is limited to the jejunum and ileum. The small intestine accounts for 75% of the total length of the gastrointestinal tract. The surface area accounts for more than 90% of the surface area of the gastrointestinal tract, but the incidence of small intestine tumors accounts for only about 5% of gastrointestinal tumors, and small intestinal malignant tumors are rare, accounting for about 1% of gastrointestinal malignancies. The incidence of primary small intestine tumors is 0.2% of all tumors in the body, accounting for 3% to 6% of gastrointestinal tumors. The exact cause of small bowel tumors is still unclear. basic knowledge The proportion of sickness: 0.5% - 0.7%. Susceptible people: no specific population Mode of infection: non-infectious Complications: intestinal obstruction peritonitis gastrointestinal bleeding

Small bowel tumor cause

(1) Causes of the disease

The cause of small bowel tumors is still unclear. The more consistent views are:

1 small intestine adenomatous polyps, adenocarcinoma and some hereditary familial polyposis are closely related;

2 Anaerobic bacteria may play a role in some small intestinal tumors;

3 immunoproliferative small intestinal disease (IPSID) is considered to be a precancerous lesion of lymphoma. Evidence from all aspects suggests that infection may play an important role in the development of IPSID lymphoma;

4 inflammatory bowel disease has a tendency to develop into small intestinal malignant tumor;

5 Some diseases such as oral inflammatory diarrhea, Crohn's disease, neurofibromatosis, some ileal surgery are related to the occurrence of adenocarcinoma; others such as nodular lymphoid hyperplasia, AIDS is associated with non-Hodgkin's lymphoma ; 6 chemical carcinogens such as dimethyl hydrazine, oxidized azomethane may play a role in the occurrence of small bowel tumors.

(two) pathogenesis

1. Pathological classification: There are many pathological types of small intestine tumors, and 35 reports have been reported in foreign countries. There are 20 reports in China, which can be classified as follows.

(1) Classification according to the degree of differentiation: According to the degree of differentiation of tumor cells, it is divided into benign tumors and malignant tumors.

1 benign tumor: A. adenoma or polyp; B. leiomyomas or adenomyoma; C. fibroids; D. lipoma; E. hemangioma; F. neurofibromatosis, schwannomas; G. Tumor, teratoma, lymphangioma, melanoma and others.

The most common benign tumors are adenoma, leiomyomas, lipoma, fibroids, and hemangioma. Domestic reports of jejunal leiomyoma account for 38-54%.

2 malignant tumors: A. cancer (adenocarcinoma, papillary carcinoma, mucinous adenocarcinoma); B. sarcoma (fibrosarcoma, neurofibrosarcoma, leiomyosarcoma, reticulum sarcoma, mucinous sarcoma); C. carcinoid or argyrophilic Cell tumor; D. Hodgkin's disease; E. malignant hemangioma; F. malignant pigmentoma; G. malignant schwannomas.

Most of the malignant tumors are cancerous, followed by various types of sarcoma. The sarcoma ranks first in all kinds of malignant lymphomas, accounting for 35-40%, and the ratio of cancer to sarcoma is 1:5.5.

(2) Classification by tissue source: can be divided into epithelial tumors and non-epithelial tumors.

2. Tumor distribution: Different small intestine tumors appear in different parts of the small intestine and appear to have a certain tendency.

There was no difference in the incidence of malignant tumors in different segments of the small intestine. In benign tumors, the incidence of duodenal tumors was significantly lower than that of empty and ileum, and there was no difference between the latter two.

Small bowel tumor prevention

Small intestine malignant tumor surgery requires extensive resection and anastomosis of the diseased intestinal segment and regional lymph nodes. For duodenal malignant tumors, most of them need duodenal pancreatic head resection.

If the small intestine tumor is locally fixed and cannot be removed, it can be used as a bypass procedure to relieve or prevent obstruction.

Early diagnosis of small intestinal malignant tumors is difficult, the resection rate is about 40%, the 5-year survival rate after resection is about 40% for leiomyosarcoma, about 35% for lymphoma, and about 20% for adenocarcinoma.

Radiation therapy and chemotherapy are less effective than lymphoma.

Small bowel tumor complications Complications, intestinal obstruction, peritonitis, gastrointestinal bleeding

Small intestine tumors are often seen for complications, and are commonly found in:

1. Intestinal obstruction: 1/3 of patients may have intestinal obstruction, usually chronic incomplete intestinal obstruction, vomiting and abdominal distension are not very significant, which is characterized by recurrent episodes of intestinal obstruction and self-remission.

2. Intestinal perforation and peritonitis: the incidence rate is 8.4% to 18.3%, which occurs partly on the basis of intestinal obstruction. In other cases, ulcers, necrosis, infection and intestinal perforation are caused by tumor invasion of the intestinal wall, and acute perforation causes diffuseness. Peritonitis, the mortality rate is extremely high, chronic perforation can occur intestinal adhesions, inflammatory masses, abscesses and intestinal fistula.

3. Gastrointestinal hemorrhage and anemia: The incidence rate is 18.1% to 27.9%, which is common in submucosal tumors. The cause of bleeding is mainly caused by erosion, ulceration and necrosis of the tumor surface. For example, long-term recessive bleeding, anemia occurs in patients.

Symptoms of small intestine tumors Common symptoms Weight loss, black stool, lower abdominal pain, tumor, traction, bloody tar, acute abdomen, fatigue, suffocation

Patients with small bowel tumors are more than 50 years old, with an average age of 35 years. The male and female sex are roughly equal. The common clinical manifestations of small intestine tumors are as follows:

1, abdominal pain

Common symptoms can be caused by ulceration of the surface of the tumor, stimulation of intestinal fistula caused by intestinal fistula, or due to intestinal obstruction or intussusception. When the tumor is huge, it can cause intestinal blockage when it protrudes into the intestine; tumor invading the intestinal wall can cause intestinal tube Stenosis, obstruction, such obstruction is more common in small intestine malignant tumors, intussusception is mostly caused by benign tumors of the small intestine, acute exacerbation, and repeated chronic attacks, 70% of cases have different degrees of abdominal pain, early multiple causes The tumor causes intestinal peristalsis or pulls the mesentery. The pain site corresponds to the location of the tumor. It is usually painful, painful, and painful after eating. It does not cause the patient to pay attention. If the obstruction or perforation occurs, the abdominal pain is aggravated. Therefore, see a doctor.

2, gastrointestinal bleeding

About 1/3 to 2/3 patients have bleeding due to ulceration of the surface of the tumor, most of which are recessive hemorrhage, which is characterized by positive fecal occult blood test or black feces. Iron deficiency anemia can also occur for a long time, and intermittent small amount can also occur. Bleeding, even a large amount of blood in the stool, the most likely to cause hemorrhagic leiomyoma and sarcoma, hemangioma and adenoma, neurofibromatosis, mostly long-term occult blood positive leading to anemia, occasionally blood or a lot of fresh blood, even shock, a large number When bleeding, first with paroxysmal abdominal pain, bowel sounds, followed by fresh blood, tumor location and bleeding volume, can be brown, brown red, red to bright red, such as a large number of tumors at the end of the ileum, then The blood color is bright red, the hemorrhage and tar-like stool may appear in the proximal jejunum, and the bleeding rate of smooth muscle tumor, hemangioma and malignant lymphoma is high, and the extraluminal smooth muscle tumor can be broken and cause intra-abdominal hemorrhage.

3, abdominal block

Because the activity of the small intestine is large and the position is not fixed, the small intestine tumor can occasionally reach the mass during the physical examination, but sometimes it can not be found, sometimes it is not. Most of the tumors that can be affected and the mass are small intestinal sarcoma, nearly half Cases can reach the mass in the abdomen. The jejunal tumor often touches the mass in the left upper abdomen. The mass of the ileal tumor is mostly accessible in the lower abdomen or the lower right abdomen. The extraintestinal tumor is mostly bulky, the benign tumor surface is smooth, the boundary is clear, and the activity Larger degree, most of the malignant tumors are unclear, the surface is not smooth, hard, and the movement is small. If the tumor is hidden, it is accompanied by abdominal paroxysmal pain. In adults, it should be considered as tumor intussusception. .

4, intestinal obstruction

For intestinal stenosis, blockage caused by intussusception, intestinal cavity compression or intestinal tube torsion, its occurrence is related to tumor growth mode, its growth pattern is: 1 growth into the intestinal lumen: small polypoid tumor Such as small intestine adenoma, lipoma, fibroids, etc., more induced intussusception, paroxysmal abdominal pain, vomiting, abdominal mass touching the mass, the symptoms disappear after the mass disappears, the above symptoms recurring, large tumors often block the intestine Cavity, chronic intestinal obstruction or acute intestinal obstruction, due to abdominal distension, abdominal mass is often not easily touched. 2 Infiltration and growth along the intestinal wall: causing narrowing of the intestinal lumen, mostly in adenocarcinoma, and the disease progresses rapidly. 3 growth outside the intestinal wall: this type of tumor often occurs when the symptoms appear, causing the small intestine to fold, twist, or the tumor and the large net adhesion to compress the intestine, or invading the surrounding intestine to cause intestinal stenosis, obstruction, more common in the small intestine malignant lymph Tumor, adenocarcinoma, and lymphosarcoma have early intestinal obstruction.

The clinical manifestations vary with the location of the obstruction. High intestinal obstruction may manifest as upper abdominal discomfort or pain, hernia, nausea and vomiting; low intestinal obstruction may manifest as umbilical pain, spastic colic, bloating, vomiting, etc. Bulging, a small number of intestinal types appear, auscultation of bowel sounds is paroxysmal or gas over the water, palpation has a partial touchable mass.

5, intestinal perforation

Occurred in advanced cases, mostly leiomyosarcoma and malignant lymphoma, acute perforation due to tumor rupture, acute peritoneal inflammation, if it has been wrapped by the omentum or surrounding intestine before rupture, perforation forms an abdominal abscess, the patient first Sustained abdominal pain, abdominal distension and other gastrointestinal symptoms, accompanied by fever and abdominal painful mass, anti-inflammatory treatment symptoms are slightly relieved, but can not completely subside, abscess perforation to free abdominal cavity, diffuse peritonitis occurs; pierced into the intestinal tract, intestinal fistula, After the occurrence of diarrhea, discharge of pus and blood, abdominal symptoms and signs are alleviated; worn to the bladder, uterus, symptoms of small bowel bladder spasm and small intestine uterus.

6, systemic symptoms

In addition to repeated anemia caused by anemia, small intestinal malignant tumors can still cause systemic symptoms such as weight loss and fatigue.

Most patients with small bowel tumors, benign or malignant, due to abdominal pain and melena or blood in the stool, such as the initial diagnosis of the exclusion of common causes, or comprehensive examination still failed to make a diagnosis, should be considered for the possibility of small intestinal tumors for further examination .

First of all, first intestine X-ray examination, such as duodenal lesions can be used for low-end duodenal angiography, empty ileal sputum examination is more difficult, because the contents of the small intestine to run faster; small intestine is long, in the abdominal cavity Make the image overlap before and after, it is difficult to distinguish, such as the tumor is larger protruding into the cavity, showing filling defects; if the tumor infiltrate the intestinal wall is wide or cause intussusception, you can see the proximal small intestine dilatation and tincture blocked , stenosis, cup shadow, etc.; sometimes visible mucosal damage, etc., when the tumor is small and does not cause stenosis, obstruction, traditional small intestine tincture examination method is difficult to find the lesion, in recent years, small intestine irrigation method seems to help, completely Sexual or close to complete obstruction, can not be used as an expectorant to avoid complete obstruction.

There are gastrointestinal bleeding, the amount of bleeding is estimated to exceed 3 ~ 5ml per minute, can be used for selective abdominal and superior mesenteric artery angiography to locate the bleeding lesions.

When suspected duodenal tumor, in addition to duodenal hypotonic angiography, duodenoscopy can be used to directly understand the lesion location, size, morphology, and biopsy, although the enteroscopy has now come out , but has not been promoted and applied.

Abdominal CT examination can show the approximate location of the small intestine tumor, the size and relationship with the intestinal wall, and the presence or absence of liver metastasis and abdominal aortic anterior and hilar lymphadenopathy, but when the tumor is small, the diameter is less than 1.5cm Hard to find.

Many small intestine tumors have not been clearly diagnosed by the above various tests. If necessary, laparotomy can be considered, and even multiple operations are necessary to confirm the diagnosis. It is difficult to diagnose small intestine tumors.

Small bowel tumor examination

1. Blood routine: Anemia manifests in the case of tumor hemorrhage, such as reduction of red blood cells and hemoglobin; in the case of abdominal infection, the white blood cell count increases and the proportion of neutrophils increases.

2. Fecal occult blood test: can be continuous positive.

3. Urine 5-hydroxylamine acetic acid and blood serotonin determination: If the clinical manifestations of carcinoid syndrome, quantitative determination of urine 5-hydroxylamine acetic acid and blood serotonin levels can determine the diagnosis.

4. Small bowel sputum angiography: traditional sputum angiography because of the discontinuity of tincture filling in the small intestine, overlapping images and rapid peristalsis, the correct diagnosis rate is only 50%, and the diagnostic rate is improved by improving the contrast method, but small The rate of missed diagnosis of tumors is still high.

(1) double contrast of small intestine hypotonic air sputum: oral sputum and foaming agent, when the sputum agent will fill most of the small intestine, give 654-2, 20mg intramuscular injection or intravenous injection to relax the intestine, after the peristalsis stops Segmental compression examination of the intestine can better display the intestinal mucosal changes in the lesion site, improve the diagnostic accuracy, and is often used clinically.

(2) sputum mannitol angiography: 20% mannitol 250ml diluted tanning agent into a suspension orally, due to faster bowel movements, sputum quickly reaches the small intestine for rapid development, the advantage of this method is rapid development, clearly showing intestinal peristalsis And appearance, such as the unexplained tincture through slow or dilated bowel, may be a tumor sign, but can not show a small lesion in the mucosa.

(3) segmental angiography of the small intestine: the sputum and foaming agent are injected into the distal part of the duodenum through the gastric tube, and the small intestine is examined by segmental angiography, which shows the stenosis of the intestinal segment, the filling defect, the filling defect, the mucous membrane is not The rules, or changes in the external pressure of the intestines, the operation of this method is more complicated and time-consuming, the patient has some pain and is not easy to accept.

X-ray findings of small intestine tumors include: 1 filling defect; 2 intestinal fistula shift; 3 shadow; 4 soft tissue shadow, mucosal morphology change, intestinal wall stiffness and slow motility; 5 intestinal stenosis, intussusception or obstruction, intestinal malignant lymphoma X The line has certain characteristics, which can show aneurysmal changes, thickened intestinal wall, and narrowed intestinal tube, showing multiple nodular stenosis.

5. Fiber endoscopy: endoscopic examination of small bowel lesions, due to operational difficulties, low success rate; at the same time limited by the endoscopic field of view, the diagnostic rate is not high, although in recent years improved endoscopy and examination methods, diagnostic rate Still not satisfied.

(1) duodenoscopy or child colonoscopy: can clearly observe the jejunum within 60cm below the duodenal suspensory ligament, fiber colonoscopy through the ileocecal sneak peek at the terminal ileum, to the distal jejunum and proximal ileum can only Fiber enteroscopy is used, but the success rate of insertion is extremely low.

(2) Sonda enteroscopy: a small intestine with a balloon or probe with a diameter of 5 mm, a length of 2600 mm or a diameter of 6.8 mm and a length of 2760 mm. After insertion into the stomach, the enteroscopy is carried to the small intestine with the gastrointestinal motility. In 50% of cases, the endoscope can reach the distal end of the ileum, but due to the limitation of the field of view, only 50% to 70% of the intestinal mucosa can be peeped.

(3) enteroscopy-sputum enema examination: that is, after the endoscopy, the guidewire is placed through the enteroscopy, the colonoscopy is withdrawn, the catheter is inserted into the small intestine through the guidewire, and the expectorant is injected into the small intestinal fistula. Through examination, the simultaneous inspection of enteroscopy and expectorant can complement each other's deficiencies, avoiding the pain of two examinations, and the diagnosis rate is increased to 70%.

6. Selective superior mesenteric artery angiography: suitable for cases of gastrointestinal hemorrhage, inferring the nature of the tumor and the site of bleeding through the image of abnormal blood vessel distribution, imaging findings of smooth muscle tumor, hemangioma and malignant tumor, which is helpful for diagnosis For endoscopic examination of gastrointestinal bleeding from the esophagus, stomach, colon, bleeding volume >0.5ml / min, feasible emergency mesenteric artery angiography, bleeding site abnormal concentration of contrast agent, or abnormal movement of veins The imaging features of malignant tumor angiography are: 1 see infiltration or displaced blood vessels; 2 neovascularization; 3 cystic changes or necrosis, contrast agents form "lake", "pool", 4 sinus"; 4 tumors surrounding the stenosis, occlusion; 5 capillary perfusion time prolonged or increased permeability, tumor staining; 6 arteriovenous shunt, the diagnosis rate of this method for bleeding cases is 50% to 90%.

7. B-type ultrasound examination: In order to avoid interference with the contents of the intestine during the examination, the ultrasound examination should be carried out before the examination of the expectorant. Only one half of the food is eaten for dinner one day before the examination, and the laxative is taken before going to bed, and the enema can be cleaned if necessary. After a routine abdominal scan in the fasting state, the case of suspected mass or thickening of the intestinal wall is 500ml. After 30min, it is checked every 10~15min. The flow of water can better show the location, size and shape of the tumor. The internal structure, the relationship with the intestinal wall, the depth of infiltration, the surrounding lymph nodes, and also the distant metastasis, the normal intestinal wall thickness in the filling state is about 3mm, generally not more than 5mm, if necessary, under the B-mode ultrasound guided biopsy, However, care should be taken to avoid damage to the intestines or blood vessels.

8. Abdominal CT and magnetic resonance imaging (MRI): Some small intestine tumors such as lipoma, smooth muscle tumor, and malignant lymphoma have specific CT and MRI imaging findings, which are valuable diagnostic methods. Intra-abdominal lymph nodes, liver, spleen and other organs metastasis, but small tumors can not show their unique CT, MRI images, CT examination can understand the tumor size, location and the relationship between the tumor and surrounding tissues, infer its properties according to the tumor tissue density, oral Contrast agent for CT scan can show abnormalities of the intestinal lumen, destruction, shadow and sinus, and can clearly show the soft tissue mass and local lymphatic metastasis extended to the cavity. For extraluminal tumors, the edge is often clear. The huge mass, oppression of the adjacent intestine, can also show tumor necrosis, liquefaction and cystic changes, CT can also be used for staging of malignant tumors:

Stage I: intraluminal mass, the lumen wall is not thick (normal small intestine wall <5mm).

Stage II: thickening of the wall (>10mm), no invasion of adjacent organs, no lymph node metastasis.

Stage III: wall thickening and direct invasion of surrounding tissue, local lymph node metastasis, but no distant metastasis.

Stage IV: There is a distant transfer.

9.99mTc labeled red blood cell scan: suitable for chronic, small amount of bleeding cases, through the accumulation of nuclide in the intestine, inferred gastrointestinal bleeding site, 99mTc labeled red blood cells injected into the body 24h, gradually cleared by the liver, spleen, there is blood during this period Extravasation, showing hot spots in the blood accumulation area, this method is slow in bleeding, the case of bleeding volume >0.1ml per minute, can show the bleeding site, the diagnostic value is better than angiography, but must be tested multiple times, otherwise enter the intestine The nuclide has moved distally during scanning and cannot be accurately located.

10. Double-chamber balloon catheter insertion test: After the nasal cannula is inserted into the small intestine with the balloon, the small intestine is moved to the distal side, and the contents of the small intestine are taken one by one for cytology and routine examination to determine the bleeding site and find the tumor cells. The suspicious intestinal segment was injected with contrast agent under fluoroscopy, and the changes of the intestinal wall and mucosa were observed. The operation was complicated and time-consuming, and the positive rate and correct rate of cytological examination of intestinal contents were also unsatisfactory. Clinical application not much.

11. Laparoscopy: In recent years, it has been reported that laparoscopic observation of each segment of the small intestine, cutting part of the diseased intestine and mesenteric lymph nodes and pathological examination, especially in the differential diagnosis of malignant lymphoma and Crohn disease have a certain diagnostic significance.

Diagnosis and diagnosis of small intestine tumor

diagnosis

The correct diagnosis rate of small bowel tumors before surgery is only 21% to 53%, and the reason for the correct diagnosis rate is low: 1 lack of characteristic symptoms, abdominal pain caused by proximal jejunum, duodenal tumor, bleeding and ulcer disease, chronic gastritis, etc. Symptoms are similar. Abdominal pain caused by tumors at the end of the ileum is often misdiagnosed as appendicitis, intestinal tuberculosis or gynecological diseases; 2 is the symptoms of acute abdomen, and the signs are concealed. Most patients start to see up when complications occur, and data cannot be collected comprehensively before surgery. Detailed examination; 3 no ideal examination method; 4 doctors have not enough knowledge of the disease, did not pay attention to the early symptoms of the patient, resulting in delayed diagnosis, Maglinte data show that patients with small bowel tumors due to the doctor did not propose appropriate inspection methods, the average delay The diagnosis is as long as 8.2 months. Therefore, the following symptoms and signs should be vigilant: 1 Unexplained umbilical or right lower abdominal pain, increased after eating, vomiting, relief of symptoms after defecation; 2 adult intussusception; 3 intermittent Asphalt, blood in the stool or diarrhea, no abnormalities in the fiber endoscopy or colonoscopy; 4 unexplained intestinal obstruction, an auxiliary examination can help to confirm the diagnosis.

Differential diagnosis

Small intestine tumors are mainly characterized by abdominal pain, nausea, vomiting, gastrointestinal bleeding, abdominal mass, anemia, weight loss, etc., so they should be identified by the following diseases:

Colon cancer: In addition to abdominal pain and abdominal mass, there are also changes in bowel habits and fecal traits, which are different from small bowel tumors and are easier to distinguish.

Intussusception: a segment of the intestine is inserted into the distal or proximal lumen of the intestine, so that the intestinal wall overlaps and congested in the intestine, called intussusception. 80% of the disease occurs in children less than two years old. Suddenly, the main performance: abdominal pain, vomiting, blood in the stool, abdomen "sausage-like mass".

Peptic ulcer: Upper abdominal pain is one of the most common symptoms of ulcer disease. It is often rhythmic, periodic and long-term. The nature of pain is often pain, burning, pain, hunger or severe pain. Paroxysmal moderate dull pain, also persistent pain, can temporarily relieve alkaline drugs and food.

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