Benign tumor of duodenum

Introduction to benign tumors of the duodenum Benign tumor of duodenum (benigntumorofduodenum) is rarer than malignant tumors, and the ratio of good to malignant is 1:2.6 to 1:6.8. Although the benign tumor of the duodenum itself is benign, some tumors have a high tendency to malignant transformation, and some of them are between good and bad, and even difficult to identify even under the microscope. In particular, the location of tumor growth is often closely related to the bile and pancreatic drainage system. The location is fixed, and the duodenum's intestinal lumen is relatively narrow, so it often causes various symptoms, and even serious complications are life-threatening. Due to the special position of the duodenum, the surgical treatment of these tumors is very tricky. basic knowledge The proportion of illness: 0.0003% Susceptible people: no special people Mode of infection: non-infectious Complications: jaundice

Causes of benign tumors of the duodenum

(1) Causes of the disease

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(two) pathogenesis

The more common pathological types of benign tumors of the duodenum are as follows:

1. adenoma (adenoma): most adenomas are papillary or polypoid, protruding on the mucosal surface, can be single or multiple, is the most common benign tumor of the duodenum, according to its pathological features can be divided into:

(1) tubular adenoma (tubular adenoma): this adenoma is mostly single, polypoid growth, mostly pedicle, easy to hemorrhage, the basement is generally larger, histologically mainly by the proliferative intestinal mucosa Body composition, epithelial cells may have mild heteromorphism and belong to true tumors.

(2) papillary adenoma (popillary adenoma) and villous adenoma (villous adenoma): due to the easy carcinogenesis of such tumors, it is reported that 21% to 47% of duodenal cancer is from duodenal villous adenoma This kind of adenoma is increasingly subject to clinical attention and vigilance. This adenoma is often single-shot, with a papillary or villous bulge on the surface, a wide base, no pedicle or short pedicle, and histological findings. The surface of the adenoma is covered by one or more columnar epithelium, and the interstitial is rich in blood vessels, so it is very easy to bleed clinically. The columnar epithelial cells contain a large number of mucous cells, which may have different degrees of heteromorphism, so the malignant rate is greater than that of the gland. Tumor-like polyps, different literature reports that the malignant rate is 28% to 50%.

(3) Brunner tumor: also known as polypoid hamartoma or nodular hyperplasia, the tumor is mostly located under the mucosa, a polypoid-like protrusion, the diameter can be several millimeters to several centimeters, no obvious capsule, microscopically visible under the mucosa Duodenal gland hyperplasia, separated by fibrous smooth muscle into lobular structures of varying sizes. This adenoma has few malignant changes except for the typical hyperplasia of cells.

(4) non-neoplastic polyps: such as hyperplastic polyp (hyperplastic polyp) and inflammatory polyp (inflammatory polyp), are non-neoplastic polyps, generally can disappear on their own.

(5) Gastrointestinal polyp syndrome: such as Gardner syndrome, Peutz-Jeghers syndrome, familial adenomatous polyposis (FAP), etc. These lesions are multiple and can be distributed in the whole digestive tract. The lesions of the duodenum can be malignant.

2. Leiomyoma: The duodenal leiomyomas originate from the interstitial tissue of the embryo. The cause of the disease is unknown. The smooth muscle tumor consists of a group of smooth muscles with distinct boundaries, often single, round or oval. Sometimes it is lobulated, the diameter is less than 1cm, and the larger one can exceed 10cm to 20cm. There are many ways of tumor growth, which can be inserted into the intestine, or can grow in the intestinal wall or outside the intestine. The texture is generally tough. Sometimes, degeneration can occur, and the surface mucosa of the leiomyoma is rich in blood vessels, so it can cause massive bleeding of the digestive tract due to erosion and ulceration. If the tumor cells of benign leiomyomas are abnormally active in mitosis, it indicates malignant transformation and malignant transformation. The rate is 15% to 20%. According to the statistics of Peking Union Medical College Hospital, the common site of duodenal leiomyomas is mostly in the duodenal descending and horizontal parts. The incidence of middle-aged people is more common, with an average age of 56.6 years. .

3. Carcinoids and neuroendocrine tumors: Generalized carcinoids include many endocrine tumors, and carcinoids of the gastrointestinal tract originate from intestinal chromaffin cells (ECL), which belong to a family of common Biochemical characteristics of amine precursor uptake and decarboxylation cells (APUD cells) are the common origin of many neuroendocrine tumors. The neuroendocrine tumors in the duodenum are mostly asymptomatic except for gastrin. The diameter is about 1~5cm, 60% is benign. The more common ones are: gastrinoma, somatostatinoma, gangliocytic paraganglioma. The tumor is mainly distributed in the near Duodenum, the most common around the ampulla of the duodenum, may be related to local cell secretion function. It is worth mentioning that in Zhuo-Ai syndrome, 70% of gastrin tumors Located in the duodenum.

4. Other:

In some cases, rare duodenal benign tumors include lipoma, hemangioma, fibroma, hamartoma and the like.

Duodenal benign tumor prevention

There is no effective preventive measure for this disease. Early detection and early diagnosis are the key to the prevention and treatment of this disease.

Duodenal benign tumor complications Complications

jaundice.

Symptoms of benign tumors of the duodenum Common symptoms Hernia, abdominal discomfort, nausea, abdominal mass, vomiting, abdominal pain, loss of appetite, black stool

The clinical symptoms of benign tumors of the duodenum have no obvious characteristics, which is the main reason for the early diagnosis of many patients. Some tumors have almost no clinical symptoms in the early stage, and a small number of patients are accidentally discovered by laparotomy for other diseases. As the tumor grows, most patients develop various symptoms.

1. General symptoms:

Can appear upper abdominal discomfort, loss of appetite, hernia, acid reflux and other similar chronic gastritis, symptoms of gastric ulcer disease, therefore, easy to be confused with these digestive diseases.

2. Abdominal pain:

About 30% of patients with duodenal adenomatous polyps may have intermittent upper abdominal pain with nausea and vomiting. The pedicled duodenal polyps can cause duodenal jejunal intussusception when they are below the descending level. The large adenoma of the ball can be retrograde into the pylorus, leading to acute pyloric obstruction, called ball valve syndrone. The leiomyomas in the duodenum are due to tumor traction, intestinal peristalsis and tumor. Central necrosis and secondary inflammatory reactions, ulcers, perforation, etc. can cause abdominal pain, and a large benign duodenal mass such as causing intestinal obstruction can also cause corresponding abdominal pain, nausea, vomiting symptoms.

3. Gastrointestinal bleeding:

25% to 50% of patients with duodenal adenoma and leiomyomas can develop symptoms of upper gastrointestinal bleeding, which is mainly caused by ischemia, necrosis and ulceration on the surface of the tumor. The clinical manifestations are acute hemorrhage and Chronic hemorrhage, acute hemorrhage with hematemesis and melena; chronic hemorrhage is mostly a small amount of bleeding, fecal occult blood test positive, can lead to iron deficiency anemia, also reported large duplication of duodenum and hemangioma caused by digestive tract Major bleeding.

4. Abdominal mass:

A large benign tumor of the duodenum can be the main symptom of the abdominal mass, especially the leiomyomas that grow outside the intestine. It can be rubbed and lumped during the abdominal examination. It is generally fixed and the boundary is clear. Its texture is due to pathological nature. Different, soft and smooth, or tough and uneven.

5. Huang Wei:

Benign masses that grow near the nipple of the duodenum, such as the lower end of the biliary tract and the nipple opening, can present varying degrees of jaundice.

6. Other:

Neuroendocrine tumors located in the duodenum may cause clinical manifestations according to their tumor cell composition, such as Zhuo-Eye syndrome caused by gastrinoma; lip and buccal mucosa pigments unique to patients with familial adenomatous polyposis Calm and so on.

Examination of duodenal benign tumors

Histopathological examination and fecal occult blood test can help diagnose the disease.

Because benign tumors of the duodenum are rare diseases, the clinical symptoms are atypical, so it is easy to be misdiagnosed clinically. The key to early diagnosis is to improve the understanding and vigilance of the disease. Commonly used auxiliary diagnosis methods are:

1. Upper gastrointestinal barium angiography:

Upper gastrointestinal sputum angiography is the first choice for diagnosis of duodenal mass. The positive rate of diagnosis of duodenal polyposis by common barium meal is reported in the literature 64%~68%, while duodenal hypotonic sputum double The positive rate of angiography can reach 93%. If you use a drug that relaxes the duodenum, such as glucagon, in the low-tension angiography, the effect is better.

The X-ray signs of adenoma are circular filling defects or translucent areas in the intestine, smooth edges, normal mucosa, and a certain degree of activity if there is pedicle. The leiomyomas are mostly round or elliptical in the duodenum. Shape defect, smooth edge, duodenal barium angiography can make up for the lack of fiber endoscopy to the poor observation of the third and fourth segments of the duodenum.

2. Fiber endoscope:

Duodenal fiber endoscopy can directly observe the duodenal tumor and can be biopsy or biopsy. There are two kinds of endoscopes, side-view and direct-view. ), due to the limitations of the observation of the third and fourth segments of the duodenum, it is advocated to use the enteroscopy to check the duodenal lesions below the duodenal papilla opening, and the upper digestive tract angiography and fiber The combination of endoscopes can effectively reduce the rate of misdiagnosis.

3. Ultrasound diagnosis:

Ordinary ultrasound has certain limitations in the diagnosis of duodenal tumors, because the gas in the duodenal cavity interferes with the observation of ultrasound images, but if the duodenal tumor grows around the ampulla, causing bile duct dilatation or pancreatic duct Expansion; large duodenal bulbs cause pyloric obstruction leading to gastric dilatation, etc. Ultrasound examination may provide indirect effects for clinical reference. Endoscopic ultrasonography performed in recent years has improved duodenal masses. The positive rate of diagnosis, especially for the submucosal lesions and the relationship between the tumor and the surrounding organs, provides valuable imaging data. The literature reports that lesions as small as 0.5cm can be found to be sensitive to tumors above 2cm in diameter. % is a diagnostic method for the application of more and more duodenal masses in clinical practice.

4. Selective arteriography:

Selective angiography has a certain diagnostic value for duodenal tumors, especially in the blood supply of duodenal tumors. On the other hand, for endocrine tumors, such as gastrinoma, by selection Angiography and selective arterial injection of secretin, and then measuring the blood gastrin level of the hepatic vein to achieve regional positioning.

5. Radionuclide scanning:

It is mainly used for the diagnosis and localization of duodenal neuroendocrine tumors. For example, when injected with 123I or 111I-labeled octreotide (somatostatin homolog), it is extremely high for gastrinoma expressing somatostatin receptor. Sensitivity, positive rate of up to 35%, but no diagnostic value for somatostatin receptor-negative lesions.

6.CT and MRI:

CT and MRI have little significance in the diagnosis of benign small tumors of the duodenum, but for large leiomyoma, neuroendocrine tumors have some help, other changes caused by duodenal tumors, such as biliary dilatation, pancreas Tube expansion, etc., has a certain imaging reference significance, the literature reports that the CT and MRI images of ganglion paracranial nerve tumors have special characteristics, mainly the tumor is homogeneous, no cystic changes, more blood, blood vessels Reticulated protrusions, etc., can be used to distinguish from other benign tumors of the duodenum.

7. Surgical exploration:

If the above examination is still unable to confirm the diagnosis, laparotomy surgery may be considered, especially for patients with unexplained upper gastrointestinal bleeding, obstruction, jaundice and highly suspected duodenal tumor. The indication for surgical exploration should be relaxed.

Diagnosis and differential diagnosis of duodenal benign tumor

Duodenal benign tumors are difficult to diagnose early, even if the above clinical manifestations are not specific to the disease, the key is to think about the possibility of this disease, timely and rational selection of endoscopic biopsy, X-ray barium meal and other examinations, more clearly Diagnosis, a small number of patients with difficult diagnosis and surgical indications, feasible surgical exploration.

Benign tumors of the duodenum should be differentiated from malignant tumors, causing obstructive jaundice, especially those with intermittent onset of jaundice and fever, and should be differentiated from common bile duct stones and cholangitis.

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