Small intestinal leiomyoma

Brief introduction of small intestinal leiomyoma Small intestine leiomyoma is the most common benign tumor of the small intestine, derived from the muscularis of the small intestine, a small number from the muscularis of the mucosa, an inter-intestinal wall tumor, which ranks second in the benign tumor of the small intestine, second only to adenoma. . basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: gastrointestinal bleeding, intestinal obstruction, peritonitis

Causes of small intestinal leiomyoma

(1) Causes of the disease

Small intestine leiomyoma occurs in the muscular layer of the intestinal wall or in the muscular layer of the mucosa. Individually derived from the muscular layer of the blood vessels, the tumors are mostly single-shot, varying in size, often round or elliptical, sometimes lobulated or nodules. Shape, the tumor texture is tough, often with obvious boundaries, the cut surface is light gray red, visible braided fiber bundles.

(two) pathogenesis

Pathological change

Small intestinal leiomyomas are expansive growth, which can be compressed to a certain extent to compress the intestinal lumen, and the mucosa is straightened. The ulceration is necrotic due to insufficient blood supply. The ulcer surface is small and shallow, and the edge has no ridge-like bulge, which can cause the intestinal tract. Bleeding or even perforation can also occur mucinous or cystic changes. The sinus often communicates with the digestive tract. The tumor can cause intussusception and intestinal torsion and cause obstruction.

(1) Histomorphology: microscopically, the tumor tissue is composed of fusiform smooth muscle cells with similar morphology, which is slightly larger than normal smooth muscle cells. The cells are woven into bundles, often arranged in a grid shape; intramuscular fibers, cytoplasm can be seen in the cells. It is rich in eosinophilic, with a long rod-shaped nucleus and fine chromatin in the nucleus. The cells are well differentiated and have no heteromorphism. Most of them have no nuclear division, and occasionally a few mitotic figures. The tumor tissue can contain varying amounts of connective tissue and Fibroblasts.

(2) Distinction of benign and malignant smooth muscle tumors: Pathologically, benign and malignant smooth muscle tumors are sometimes difficult to distinguish, and may even exist at the same time. The pathological features of small intestinal smooth muscle tumors summarized in large cases in China are as follows:

1 The number of mitotic cell divisions is 0 to 1/10 high power field (HP) or no nuclear division.

2 Myoma cells have no atypicality.

3 The density of fibroid cells is low.

4 no tumor tissue invasion.

5 fibroids are generally less than or equal to 7 cm in diameter.

6 tumors may have bleeding, but less necrosis and cystic changes; while leiomyosarcoma often occurs bleeding, necrosis and cystic changes.

2. Pathological typing

According to the location of the tumor between the intestinal wall and its growth mode, it can be divided into four types: intraluminal, intramural, extraluminal, and intraluminal.

(1) intraluminal type: the most common, accounting for 65%, the tumor grows into the intestinal lumen, and its base is wider, because it is not restricted by anatomy, sometimes it can grow to a larger volume.

(2) Intramural type: about 15% of leiomyomas, tumors are generally small, rarely more than 4cm, generally do not cause any symptoms, most of which are accidentally found during biopsy or other open surgery.

(3) Endoluminal and external type: about 10% of leiomyomas. When the tumor grows into the lumen, it also expands to the outside of the intestine. The volume is often more than 4cm. Because of the swelling of the tumor, the muscle layer is resisted by the serosal membrane. Or the mucosa layer is large, it can be a dumbbell-shaped mass, so it is also called dumbbell type.

(4) Extraluminal type: the least seen, only 8%, most of the larger volume, often necrosis and hemorrhage in the center of the tumor.

Intestinal leiomyomas can be malignant, and it is reported that about 15% to 20% of small intestinal leiomyomas can become sarcomas.

Intestinal leiomyoma prevention

1. Do not drink alcoholic beverages for a long time, quit smoking and drinking hobbies, do not overeat pickles, sour, spicy and irritating foods, and banned mildew foods. It is more important for people with chronic pharyngitis to develop good eating habits. If you are less than enough, eat more fresh fruits and vegetables.

2. Maintain proper temperature and humidity in the cold season, pay attention to air circulation. Room temperature should be 20 ° C, do not cover too much bedding when sleeping at night, to avoid excessive temperature or excessive drying, causing throat discomfort. Do not sleep in the wind, take a break after strenuous labor, do not rinse the cold bath immediately. Those with acute pharyngitis caused by colds should drink hot water or ginger soup to increase sweating. Note that the stool is smooth. Timely treatment of acute inflammation, to prevent the evolution of chronic, chronically diseased organs, more likely to malignant.

3. Strengthen labor protection. Harmful gases, dust, such as dust, chlorine, bromine, iodine, etc. in the production process need to be properly disposed of. Workers who have been in contact with harmful chemical gases for a long time should wear gas masks and protective gowns.

4, increase physical fitness and strengthen physical exercise. Commonly used cold water to wash your face, prevent colds, have labor and leisure, life is regular, outdoor activities in the morning or work.

Complications of small intestinal leiomyoma Complications, digestive tract bleeding, intestinal obstruction, peritonitis

1. Gastrointestinal bleeding: more common, about half of the patients have gastrointestinal bleeding.

2. Intestinal obstruction: generally chronic incomplete intestinal obstruction, mostly manifested as persistent abdominal pain and discomfort, paroxysmal aggravation.

3. Internal hemorrhoids: is a common complication of extraluminal leiomyoma, mostly due to ischemia, necrosis, infection or cystic rupture of the leiomyomas. The patient may develop abdominal pain, fever, and anti-inflammatory. After treatment, the abdominal mass shrinks or even disappears, and then grows up.

4. Peritonitis: In addition, tumors can also penetrate into the abdominal cavity, leading to peritonitis.

Symptoms of small intestine leiomyoma Common symptoms Abdominal pain, abdominal distension, abdominal mass, dull pain, weak diarrhea, gastrointestinal bleeding, peritonitis, black stool, acute abdomen

Early non-specific clinical manifestations, sometimes abdominal pain, more self-relieving, easily misdiagnosed as other gastrointestinal diseases, the main clinical manifestations of gastrointestinal bleeding (50%), chronic small intestinal obstruction (30%), abdominal mass (25%) , intussusception (15%) and so on.

Gastrointestinal bleeding

More common, about half of the patients have symptoms of gastrointestinal bleeding, often due to insufficient blood supply to the tumor surface mucosa, or the center of the tumor due to blood circulation disorders, ischemia, necrosis and cystic changes caused by the intestinal lumen, there are two A variety of performance, some patients are often anemia of unknown cause; another part of the patient can be manifested as acute gastrointestinal bleeding, sometimes recurrent, or even due to hemorrhagic severe hemorrhagic shock and need emergency surgery, the former is more common, can be There is persistent stagnation of fecal occult blood, black stool or tar-like stool, except for leiomyomas located in the proximal jejunum, generally no hematemesis; after the mucosa of the lesion is healed, bleeding can be stopped, but bleeding can occur again, so repeated attacks, individual patient tumors Broken into the abdominal cavity, causing blood in the abdominal cavity.

2. Abdominal pain

More common, can present intermittent dull or dull pain, gradually worsening into tingling or cramping; the pain is mostly located in the mid-abdomen or umbilical, sometimes in the left upper abdomen and the lower left abdomen, often accompanied by anorexia, fatigue , diarrhea, when the mass grows to a larger volume, can cause intestinal obstruction, intussusception, intestinal torsion or intestinal perforation and acute abdomen, sometimes abdominal pain can be relieved after general medical treatment, often easily misdiagnosed as enteritis Non-neoplastic diseases such as intestinal dysfunction, causing delays in diagnosis.

3. Abdominal block

About 1/4 of the patients in the clinic can touch the abdominal mass. Due to the anatomical features of the small intestine, the abdominal mass is not easy to detect at the early stage. It is easy to reach only when the mass grows large, and often has a large degree of activity, which can be perpendicular to the root of the mesentery. Orientation, some can even move to the whole abdomen, the texture is hard, with mild tenderness, the other is often the intussusception of the intestine, not the tumor itself, such masses are often oval, and often with abdominal pain Obviously, with the amount of nesting, the mass can be deformed, when it is large and small, sometimes even disappears, often caused by intraluminal tumors.

4. Intestinal obstruction

It is the main manifestation of endoluminal tumors. The symptoms appear generally early, usually chronic incomplete intestinal obstruction. Most of them are persistent abdominal pain and discomfort, paroxysmal aggravation, vomiting and abdominal distension are not very significant, endoluminal tumors occur. The form of obstruction is often intussusception. The tumor itself is used as the head of the intestine. The extraluminal type is less likely to have intestinal obstruction; the inter-wall type and the endoluminal type may have intestinal obstruction in the early stage.

5. Concurrency

The center of leiomyomas is ischemic, necrotic, infected or cystic, and can often penetrate the intestine to form internal hemorrhoids. It is more common in the cavity. The patient may have abdominal pain and fever. After the anti-inflammatory treatment, the abdominal mass shrinks or disappears. Then grow up again.

In addition, tumors can also penetrate into the abdominal cavity, leading to peritonitis, but this is rare.

Examination of small intestinal leiomyoma

1. Blood routine: The patient may have small cell anemia.

2. Fecal occult blood test: positive.

3. Histopathological examination: The pathological examination can be performed under the colonoscopy or abdominal cavity for the pathological examination, which has great diagnostic value.

Auxiliary inspection

1. X-ray examination: sputum intestinal angiography is a common method for the diagnosis of small intestine tumors, but the positive rate is not high, often due to oral administration of a large number of sputum to make small intestine angiography overlap and affect the examination results, small intestinal sputum double contrast angiography available In order to observe the fine structure and abnormal changes of intestinal mucosa, small intestine gas perfusion, especially segmental angiography, can help detect small intestine tumors, which is superior to conventional barium meal examination.

(1) A round or nodular mass with a clear boundary, filling the defect.

(2) Umbilical or bovine eye-like shadows.

(3) The "3" sign of the intestine.

(4) The mucosa partially disappears, and some of them are curved or horizontally expanded.

(5) Tumor tissue block shadow.

In addition, there may be: local sputum is blocked to varying degrees; local intestinal stenosis; intestinal or peripheral organs under pressure displacement; proximal intestinal lumen expansion to varying degrees.

2. Colonoscopy: small intestine leiomyomas are more common in the jejunum, proximal jejunum can be examined by enteroscopy, and biopsy can be done to confirm the diagnosis; end ileum can be colonoscopy, both can only examine part of the small intestine.

3. Selective mesenteric angiography: smooth muscle-derived tumors, blood vessels are rich, so gastrointestinal bleeding is the most common symptom of small intestinal leiomyoma, about 50% of patients may have gastrointestinal bleeding, for unexplained gastrointestinal bleeding Mesenteric angiography, looking for bleeding sites, has a certain significance for the early diagnosis of the disease, the specific performance can have contrast agent spillover, early venous filling, visible tumor blood vessels, with positioning and qualitative diagnostic value.

4. Radionuclide scanning: 99mTc imaging method has a high detection rate for gastrointestinal bleeding. When the bleeding rate is only 0.05~0.1ml/min, radionuclide can be detected from the blood vessels in the intestine, but this method is used. Rate difference.

5. B-ultrasound examination: Ultrasound examination before and after drinking water can be seen in the middle echo mass, can understand the tumor size, location, with or without capsule and homogenization.

6. CT scan: For intestinal obstruction, CT manifests as intestinal dilatation and solid space-occupying lesions; CT-induced intussusception of CT is typically characterized by target signs and comet tail sign.

7. Laparoscopy: direct observation of the abdominal mass, pathological biopsy, has a certain value for the diagnosis of the disease, but because of the traumatic examination, there are certain complications, so its use is limited.

8. Exploratory laparotomy: It is an effective means for diagnosis and treatment. For patients with high clinical suspicion of small intestinal leiomyoma, active laparotomy should be performed to prevent missed diagnosis.

Diagnosis and differential diagnosis of small intestinal leiomyoma

diagnosis

Small bowel leiomyomas are difficult to diagnose, and often misdiagnosed as other diseases, such as intestinal tuberculosis, hemorrhagic enteritis, ovarian tumors, etc. Therefore, all abdominal pain, abdominal mass, especially with repeated gastrointestinal bleeding, anemia, in the exclusion After digestive tract and large intestine diseases, or unexplained chronic incomplete intestinal obstruction, the possibility of this disease should be considered. Careful small bowel intubation, double contrast angiography, enteroscopy, angiography and radionuclide scanning should be performed. CT examination if necessary to confirm the diagnosis.

Clinical diagnosis basis

1. Clinical manifestations.

2. Laboratory and other auxiliary inspections.

3. Exploratory laparotomy: It is an effective means for diagnosis and treatment. For patients with high clinical suspicion of small intestinal leiomyoma, active laparotomy should be performed to prevent missed diagnosis.

Differential diagnosis

Enteral tuberculosis

Intestinal tuberculosis may have abdominal pain, diarrhea or constipation, lumps and other manifestations, sometimes easy to be considered as a tumor, but intestinal tuberculosis is accompanied by fever, night sweats and other tuberculosis toxemia, and often accompanied by extraintestinal tuberculosis, gastrointestinal X-ray Tincture examination showed signs of irritability, filling defects or stenosis in the ileocecal area. There were ulcers, stiffness, and stenosis in the lesions of the colonoscopy. The biopsy revealed typical tuberculosis lesions - cheese-like granuloma, anti-tuberculosis treatment. Effective, can be identified with small intestine tumors.

2. Crohn's disease (Crohn's disease)

Can also be expressed as abdominal pain, diarrhea, abdominal mass and weight loss, anemia, fever, etc., gastrointestinal X-ray angiography showed intestinal stenosis, tube wall stiffness, sputum bar-like, line-like signs, lesions in segments Sexual distribution, the most common in the terminal ileum and right colon, colonoscopy showed a segmental distribution of lesions, the mucosa between the two lesions was completely normal, the mucosa of the lesion was pebbly, or a fissure ulcer, visible in chronic cases Intestinal stenosis, inflammatory polyps, mucosal biopsy can sometimes find non-case-like granuloma, which can be identified above.

3. Secondary small intestinal malignancy

More common, melanoma is the most common tumor that causes small bowel cancer. Breast cancer is also common in the small intestine. Others such as cervical cancer, ovarian cancer, colon cancer and kidney cancer can also directly invade the small intestine or directly through the retroperitoneal lymph nodes. Invasion of the duodenum, identification mainly depends on active systematic examination, found primary cancer, such as imaging examination (X-ray, B-ultrasound, CT, etc.) and endoscopy plus histological biopsy, etc., if necessary, laparotomy .

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