periampullary carcinoma
Introduction
Introduction to cancer around the ampulla Periampullarycarcinoma refers to a malignant tumor originating from the head and neck of the pancreas, the end of the common bile duct, the Vater ampulla, the duodenal papilla, and the surrounding mucosa. These malignant tumors of different origins are collectively referred to as periampullary cancer because of their special anatomical sites, similar clinical manifestations, the same treatment methods, and even difficult to separate them during surgery. basic knowledge The proportion of illness: 0.006% Susceptible people: no specific population Mode of infection: non-infectious Complications: jaundice, biliary cirrhosis, sepsis
Cause
The cause of cancer around the ampulla
(1) Causes of the disease
The cause of VPC is not well understood at present, and may be related to factors such as diet, drinking, environment, biliary calculi or chronic inflammation, and may also be caused by malignant transformation of benign tumors.
(two) pathogenesis
VPC is generally small in size, with a diameter of 1 to 2 cm and rarely more than 3.5 cm. The cancer originates from the ampulla, and it is soft and polypoid. The surface can be eroded, congested, and isopy necrotic, which often causes intermittent Obstruction, rarely reached complete obstruction, the cancer originating from the unilateral columnar epithelium of the nipple is small papillary, easy to ischemia, necrosis, shedding and hemorrhage; the mucosa from the pancreatic duct and common bile duct is mostly nodular or Lump type, large invasive, hard, can form ulcers; from the duodenal descending medial mucosa, the cancer is mostly ulcerated; from the pancreatic head acinar often invasive growth, hard lumps, often oppressed Adjacent tissue, VPC diffusion mainly spreads along the bile duct and pancreatic duct or duodenal mucosa. Because of the low degree of malignancy and less metastasis, the course of disease is longer.
The gross specimens of the tumor are polypoid or nodular, mass or ulcer type, mostly differentiated adenocarcinoma, and the poorly differentiated adenocarcinoma accounts for about 15%. If symptoms appear, 3/4 tumors invade the main pancreas. Tube, histological classification in addition to adenocarcinoma, the remaining papillary carcinoma, mucinous carcinoma, undifferentiated carcinoma, reticulocyte sarcoma, leiomyosarcoma, carcinoid, due to the special location of the cancer, it is easy to block the common bile duct and main pancreatic duct , causing poor drainage of bile and pancreatic juice, and even obstruction, causing obstructive jaundice and indigestion, or directly infiltrating the intestinal wall to form a lump or ulcer, combined with digestive juice, mechanical damage of food, can cause duodenal obstruction and Upper gastrointestinal bleeding, the way of transfer is:
1. Spread directly to the head of the pancreas, the portal vein and the mesenteric vessels.
2. Regional lymph node metastasis, such as the duodenum, the duodenal ligament, the lymph node metastasis of the upper and lower parts of the pancreas.
3. Liver metastasis, there may be more extensive metastasis in the advanced stage.
Prevention
Periampullary cancer prevention
Early detection, early diagnosis, early treatment.
Complication
Periampullary cancer complications Complications jaundice biliary cirrhosis sepsis
1. Astragalus appeared earlier, and abdominal pain appeared at the same time or successively, progressive aggravation, is obstructive jaundice, yellow staining of skin mucosa is more obvious, can be dark green, more accompanied by itchy skin.
2. Intermittent chills, fever often caused by tumor rupture, cholestasis and biliary infection.
3. Liver, gallbladder enlargement is caused by bile duct obstruction, bile stasis, a small number of patients due to long-term jaundice caused by biliary cirrhosis, splenomegaly and so on.
Common surgical complications such as: wound infection, intra-abdominal abscess, intra-abdominal hemorrhage, sepsis, liver failure, bile duct empty field anastomosis, gastric jejunostomy anastomotic leakage, renal failure, diffuse intravascular hemorrhage.
Symptom
Symptoms around the ampulla common symptoms jaundice abdominal pain indigestion loss of appetite splenomegaly skin itching hyperthermia hepatomegaly cysts chills
The age of onset is mostly 40 to 70 years old, mostly male, and the clinical manifestations of pancreatic head cancer are very similar, mainly manifested as jaundice, upper abdominal pain, fever, weight loss, hepatomegaly, gallbladder enlargement, etc. 70% of pancreatic cancer occurs in In the head of the pancreas, half of the patients only see the doctor after 3 months of symptoms, and 10% of them see the doctor for more than 1 year.
1. Astragalus appeared earlier, with abdominal pain at the same time or successively, progressively worse, but a small number of patients may be due to tumor necrosis, bile duct recanalization and jaundice subsided or reduced, but later deepened, showing volcanic jaundice, is obstructive jaundice, Yellow staining of skin mucosa is more obvious, it can be dark green, mostly accompanied by itchy skin. Most of the jaundice is persistent. A small number of patients may be due to tumor necrosis, recanalization of the bile duct and jaundice subsided or reduced, but later deepened, showing volatility jaundice. Progressive aggravation of jaundice is a late manifestation. Note that it should not be mistaken for cholelithiasis or hepatocellular jaundice. It may have dark urine color, shallow fecal color and bile salt under the skin to stimulate the nerves and no skin itching.
2. Abdominal pain in the upper abdominal pain seen in 3 / 4 cases, and often the first symptom, early part of the patient (about 40%) due to dilatation of the common bile duct or obstruction of pancreatic juice discharge caused by increased intraluminal pressure, resulting in blunt blunt Pain, abdominal pain can be radiated to the back, often after eating, evening, night or after a fat meal, but not as serious as pancreatic head cancer, early part of the patient has dull pain under the xiphoid, can be radiated to the back, more obvious after eating, often Unrecognized, late in the range of cancer infiltration, or accompanied by inflammation, increased pain, and painful back pain.
3. Intermittent chills, fever often caused by tumor rupture, cholestasis and biliary tract infection, characterized by repeated sudden onset, transient high fever with chills, elevated white blood cells, and even toxic shock, clinically misdiagnosed as Cholangitis, cholelithiasis, treatment with antibiotics and hormones is ineffective.
4. Digestive symptoms due to lack of bile in the intestine, pancreatic juice, often cause digestive and dysfunction, mainly manifested as loss of appetite, fullness, indigestion, fatigue, diarrhea or fatty sputum, gray stool and weight loss, due to ampullary cancer Chronic hemorrhage after partial necrosis, resulting in melena, fecal occult blood test positive, and secondary anemia, cancer, peritoneal metastasis or portal vein metastases can occur ascites.
5. Liver, gallbladder enlargement is caused by bile duct obstruction, biliary stasis, often can touch the enlarged liver and gallbladder, liver texture is hard and smooth, pancreatic head cancer can often reach irregular and fixed mass in the late stage, a few The patient has biliary cirrhosis and splenomegaly due to long-term jaundice.
Examine
Examination of cancer around the ampulla
1. Fecal and urine examinations about 85% to 100% of patients with fecal occult blood test continued to be positive, mostly mild anemia, urinary bilirubin positive and urinary biliary negative.
2. Blood examination, serum bilirubin increased more than 256.5 ~ 342mol / L, alkaline phosphatase, -glutamyl transpeptidase increased, transaminase light to moderate increase, carcinoembryonic antigen, CA19-9 and CA125 Can be raised.
3. Duodenal drainage fluid examination, duodenal drainage of hemorrhagic or dark brown liquid, occult blood test positive, microscopic examination showed a large number of red blood cells, exfoliative cytology examination 60% ~ 95% of patients can find cancer cells.
4. Gastrointestinal barium meal and duodenal hypotonography, sometimes visible gallbladder pressure on the outside of the duodenum, and thickened common bile duct in the first and second junctions, duodenum The nipple is enlarged, the mucosa is irregular disorder or filling defect. The duodenal ring is enlarged in the pancreatic head cancer, and the dural side wall of the duodenum is stiffened under pressure, deformation or partial obstruction, which is shape, but Typical performance is rare.
5. B-mode ultrasonography, showing bile duct or (and) intrahepatic bile duct dilatation, gallbladder enlargement, but the diagnosis rate of ampullary carcinoma itself is lower, because this part often has duodenum and gas in the stomach And the cover of food, can provide early detection of clues for those without jaundice, and sometimes experienced local cancer can be observed.
6. CT, MRI examination is meaningful for the differentiation of pancreatic head cancer, which is helpful for the diagnosis of this disease. It can show the location and contour of the tumor. The image of ampullary carcinoma and common bile duct cancer is similar. The common bile duct and pancreatic duct can be expanded or Only bile duct dilatation, which depends on the growth mode of ampullary carcinoma; when the head of the pancreas is cancer, the head of the pancreas is enlarged, there is a mass, the pancreatic duct is dilated, the ring shadow is suddenly interrupted, and a double-ring shadow appears, indicating that the pancreatic head and the common bile duct are invaded. Sometimes, there are soft tissue shadows or abnormal signals in the dilated common bile duct.
7. ERCP, can peek into the side wall and nipple of the duodenum, showing that the nipple is swollen, the surface is irregular, nodular, brittle and easy to hemorrhage, and biopsy for pathological diagnosis, ampullary cancer, pancreatic head The diagnosis of cancer (which may have stenosis of the pancreatic duct or no development) is of great help.
8. PTC examination is better than ERCP, because the ampullary nipple is uneven, the lumen is narrow and blocked, ERCP is often not easy to be successful, PTC can show the expansion of the bile duct inside and outside the liver, and the common bile duct is irregularly filled or occluded with a "V" shape. The value of localization diagnosis and differential diagnosis, PTC has the possibility of complications such as bile leakage and biliary peritonitis, need to be vigilant.
9. Selective celiac angiography (SCA) is useful for the diagnosis of pancreatic head cancer. From the change of blood vessel position, it can indirectly determine the location of pancreatic cancer, which is beneficial for the diagnosis of pancreatic head cancer. The location of pancreatic cancer can be determined indirectly from the change of blood vessel position.
10. Nuclide examination can be used to understand the obstruction site, 75Se-methionine pancreas scan, and radionuclide defects (cold zone) appear in pancreatic cancer.
Diagnosis
Diagnosis and diagnosis of periampullary carcinoma
diagnosis
Patients with progressive, almost painless jaundice, liver and gallbladder enlargement can make a preliminary diagnosis.
1. Clinical manifestations.
2. Laboratory and other auxiliary inspections.
Differential diagnosis
Because the disease has upper abdominal distension and discomfort, jaundice, sometimes complicated with biliary tract infection, elevated serum amylase, can be misdiagnosed as bile duct stones, but according to the history of recurrent episodes, Charcot's triad, volcanic jaundice, imaging examination can be The difference, a small number can be misdiagnosed as infectious hepatitis, according to the ampullary cancer AKP increased, transaminase and serum bilirubin development is not parallel to identify, also misdiagnosed as cholangiocarcinoma, liver cancer, according to imaging bile duct cancer bile duct Eccentric stenosis, characteristic sonogram and AFP increase in liver cancer are different from this disease, sometimes confused with pancreatic cancer, but pancreatic cancer is more serious than abdominal disease, B-ultrasound, CT, etc. can be seen in the pancreas Lump, clinically available for B-ultrasound, PTC, ERCP, CT, MRI, etc., combined with symptoms, signs can diagnose the disease, and differentiated from diseases that are easily misdiagnosed.
In the past, I used to include pancreatic head cancer in cancer around the ampulla. However, the two were significantly different in the course of disease, surgical resection rate, prognosis, etc. The latter developed slowly, and the jaundice appeared early. The surgical resection rate was about 60%, 5 years. The cure rate is 40% to 45%. The pancreatic head cancer develops rapidly, and the pancreas and surrounding lymph node metastasis appear rapidly. The jaundice appears late, the surgical resection rate is about 20%, the cure is only 10% in 5 years, and the identification of 4 kinds of cancer around the ampulla. Mainly rely on B-ultrasound, ERCP, PCT and CT or MRI examination, its symptoms and other general identification points.
