small bowel adenocarcinoma
Introduction
Introduction to small intestinal adenocarcinoma Small intestine adenocarcinoma is a malignant tumor from the small intestine mucosa, mostly located around the duodenal papilla, jejunum and ileum. It is one of the most common primary malignant tumors of the small intestine. In small intestine adenocarcinoma, adenocarcinomas that occur in the duodenum tend to have early symptoms and are easy to diagnose and treat. basic knowledge The proportion of illness: 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: gastrointestinal bleeding anemia jaundice intestinal obstruction
Cause
Causes of small intestine adenocarcinoma
(1) Causes of the disease
The onset of small intestine adenocarcinoma is unclear, and the traditional concept of risk factors and geographical distribution is similar to colon cancer, but recent European multicenter studies have shown that it may be related to drinking and certain occupations, but not to smoking. Common risk factors include Crohn's disease, celiac disease, neurofibromatosis, urinary diver-sion procedtlres [eg ileocystoplasty], small intestine adenocarcinoma Similar to the adenoma-adenocarcinoma sequence of colon cancer, adenoma is a common precancerous disease, of which familial adenomatous polyposis (FAP) is the most common.
However, clinical observations showed that 65% of duodenal adenocarcinoma occurred in the area around the ampulla of Vater, and 22.5% occurred in the upper part of the ampulla in the proximal part of the duodenal papilla, which was also dominated by the descending part, and the incidence of ampullary carcinoma was high. The reason for this is unclear, but the ampulla region marks the site of the anterior midgut intestine. It is likely that the mucosa of this junction area is less resistant to disease than other parts of the duodenum, and some people think that the duodenum and the jejunum are near the gland. Cancer may be related to the carcinogenic effects of certain bile acids (such as deoxycholic acid, choline, etc.) in the bile under the action of bacteria.
Long-term Crohn's disease can occur in adenocarcinoma (occurrence rate 3% to 60%), and the site is mainly ileum. The risk of carcinogenesis of Crohn's disease is 300-1000 times higher than that of the normal control group. It is reported that there are about 30% of cases. Tumors occur in the intestine segment of bypass surgery due to Crohn's disease. The incidence of small intestine adenocarcinoma is significantly higher in patients with celiac disease and colorectal cancer than in normal controls. Cases of familial colonic polyposis and Gardner syndrome occur. The possibility of duodenal adenocarcinoma was also significantly higher than that of the normal control group.
Small intestine adenocarcinoma is often accompanied by genetic alterations, such as oncogene activation, tumor suppressor gene deletion, etc. Sutter reports that 5 of 6 small intestinal adenocarcinomas have a point mutation in the 12th codon of K-ras gene; Hidalgo found 5 The expression of p53 protein was overexpressed in %~10% of adenocarcinoma cells, and the intensity of expression was significantly correlated with the degree of differentiation, invasion, metastasis and prognosis of small intestine.
(two) pathogenesis
Pathological morphology
Small intestine adenocarcinoma originates from the small intestine mucosa, from the mucosa to the muscular layer, the serosal layer develops, and simultaneously spreads to the periphery. The length of the small intestine adenocarcinoma invading the intestine is generally only 4 to 5 cm, rarely exceeding 10 cm, so clinically There are few patients who have a visit to the abdomen.
(1) Gross morphology: Gross pathological specimens can be divided into three types:
1 annular infiltrating adenocarcinoma: also known as stenosis, the lesion grows along the transverse axis of the intestine, and finally forms a ring-shaped lesion, the intestinal lumen is narrowed, the intestinal wall is thickened and hardened, and it is easy to cause intestinal obstruction.
2 polypoid papillary carcinoma: more common, protruding into the intestinal lumen, easy to cause intussusception, and gradually infiltrate the intestinal wall to cause annular stenosis.
3 ulcerated cancer: As the lesion develops into the deep layer, the mucous membrane appears to be erosive, and then ulceration, ulceration, this type is easy to cause chronic gastrointestinal bleeding or even perforation caused peritonitis; may also be adjacent to the intestine before the perforation, so After piercing, it communicates with it to form a guilt.
(2) Histomorphology: The characteristics of the microscope are the formation of gland structures of different sizes and shapes. The hyperplasia of the glands is sometimes very dense, so that they are close to each other. It is difficult to see the existence of interstitial cells. Large, dyed deep, nuclear size is different, polarity is disordered, mitotic figures are more common.
2. Organization type
According to cell morphology and degree of differentiation, it can be divided into high, medium and poorly differentiated adenocarcinoma, mucinous adenocarcinoma and undifferentiated carcinoma. Among them, adenocarcinoma with better differentiation is the most common.
3. Transfer route
The spread of cancer can be transferred to the mesenteric lymph nodes and the liver, peritoneum, and other abdominal organs through direct infiltration or regional lymphatic vessels. Duodenal adenocarcinoma can be transferred to the pylorus, pancreatic head, hepatic hilum, and para-aortic lymph nodes. Advanced cancer can penetrate the intestinal wall and invade adjacent organs.
4. Pathological staging
According to the Duke's staging method revised by Astler Coller, small intestine adenocarcinoma is divided into four phases:
A. Cancer is limited to the mucosa and submucosa, no lymph node metastasis.
B1. The cancer infiltrates the muscularis propria and has no lymph node metastasis.
B2. The cancer penetrates the muscularis propria and has no lymph node metastasis.
C1. Cancer infiltrates the muscularis propria, regional lymph node metastasis.
C2. The cancer penetrates the muscularis propria and regional lymph node metastasis.
D. Distant metastasis (including hematogenous metastasis, para-aortic lymphatic metastasis, abdominal cavity implantation and extensive infiltration of adjacent organs).
Prevention
Small intestine adenocarcinoma 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.
Complication
Small intestine adenocarcinoma Complications, gastrointestinal bleeding, anemia, jaundice, intestinal obstruction
Gastrointestinal bleeding
More common, most of them are chronic blood loss, mainly black stools, and long-term chronic blood loss is anemia.
2. Huang Wei
The mass compresses the common bile duct or the duodenal papilla and causes obstructive jaundice due to obstruction of the bile duct.
Chronic incomplete intestinal obstruction, hemorrhagic anemia is a common complication of small intestine adenocarcinoma. Adenocarcinoma occurs in the duodenal papilla and can also cause obstruction of the bile duct.
Symptom
Small intestine gland cancer symptoms Common symptoms Dull pain, abdominal distension, blood loss, appetite, fatigue, peritoneal irritation, jaundice, chronic abdominal pain, nausea and intestinal perforation
The clinical manifestations are mostly related to the location of the tumor. Common manifestations include abdominal pain, gastrointestinal bleeding, intestinal obstruction, weight loss, nausea, vomiting, anemia, fever, etc. Duodenal adenocarcinoma still has jaundice, and abdominal mass is rare.
Abdominal pain
Generally, it is chronic abdominal pain, which is not closely related to diet. It is mild in early stage and easily misdiagnosed as "stomach pain". The pain is mostly in the middle or right side of the upper abdomen. It is persistent dull pain, pain, pain, and gradually worsens, causing loss of appetite. , weight loss, fatigue, and intestinal obstruction, abdominal pain during intestinal perforation.
2. Obstructive symptoms
It is often one of the main reasons for patients to see a doctor. Ring-shaped stenosis is often characterized by chronic incomplete intestinal obstruction. The mass is invasive, causing intestinal stiffness, stenosis, intestinal obstruction, and patients often have vomiting, bloating, and vomit. For stomach contents, with bile or blood.
3. Gastrointestinal bleeding
More common, ulcerated adenocarcinoma surface due to vascular erosion, ulceration can occur paroxysmal or persistent gastrointestinal bleeding, most of the chronic blood loss, mainly black stool, when the lesion involves large blood vessels, there may be a lot of bleeding, It is characterized by hematemesis or blood in the stool. The stool is black or dark red, and even hypovolemic shock occurs. Long-term chronic blood loss has anemia.
4. Abdominal mass
The size of small intestine adenocarcinoma is generally small, and there are few tumors. It is reported that about 1/3 of patients may have abdominal masses at the time of treatment, which may be a thickened intestine in the proximal end of the obstruction. Sometimes it may be grown outside the cavity. Hemorrhoids and lumps can have tenderness, and the weight of the thinner is clear.
5. Huang Wei
80% of duodenal descending tumors are caused by jaundice. The lumps compress the common bile duct or duodenal papilla and cause obstructive jaundice due to obstruction of the bile duct. The early stage shows volatility and persists and gradually deepens.
6. Signs
The patient may present with weight loss, anemia, and tenderness in the abdomen. The tender part is often the site of the mass, and the abdominal mass may be touched in the late stage. The intestinal obstruction may have intestinal and peristaltic waves, the bowel sounds hyperthyroidism, and the intestinal perforation may have a peritoneum. Stimulating signs, sometimes liver metastases can reach the enlarged liver.
Examine
Small bowel adenocarcinoma
1. Histopathological examination: for duodenal adenocarcinoma can be used for duodenal fluid cytology examination, but the success rate of duodenal drainage is not high, time-consuming, the patient is difficult to cooperate, and is currently used less.
2. Blood routine examination: small cell anemia can be found.
3. Fecal occult blood test: can be positive.
4. Serum bilirubin examination: duodenal ampullary tumor can appear serum combined with bilirubin increased.
Film degree exam
Digestive tract sputum angiography
The positive rate of digestive tract barium meal examination is low, and a large amount of barium should be taken orally, and it is usually interfered by the overlapping image of small intestine, which affects the judgment of results. Oral or ductal hypotonic duodenal angiography can clearly show duodenal lesions. The mucosal image and its nature have a diagnostic value for duodenal tumors, the correct rate is 53% to 62.5%. The whole digestive tract gas contrast can observe the fine structure of the mucosa and its abnormal changes, and diagnose the small intestine cancer. Some help, experienced physicians can detect the early lesions, the small intestine perfusion examination is to place the duodenal catheter at the distal end of the duodenal jejunum, continuously injecting dilute sputum and injecting gas to show the outline of the small intestine , lumen and mucosal folds.
The X-ray image appears as:
(1) Mass-type adenocarcinoma, irregular lobulated or cauliflower-like filling defects in the intestine, and often can cause intussusception (Fig. 3). If ulcers form, it shows irregular cavity shadows.
(2) infiltrating stenotic adenocarcinoma, the intestine cavity is a circular concentric stenosis, the proximal part of the stenosis, the distal end of the lesion protrudes in the intestinal lumen, so that the intestinal lumen of the lesion is in the form of "apple core", the core is Cancer ulcers.
(3) The intestinal lumen in the proximal side of the lesion often has different degrees of dilatation. Sometimes, the back pressure trace may appear at one or both ends of the lesion. This is because the intestinal tube of the lesion is completely demarcated from the normal intestinal tube above and below. Through the lesion area, the normal intestinal tube with frequent peristalsis is covered on the mass.
(4) The mucosal folds of the lesion disappeared, the wall was stiff, and the peristalsis disappeared.
2. Fiber endoscopy
Duodenal adenocarcinoma can be diagnosed with fiber duodenoscopy, the rate of diagnosis is 90% to 100%, not only can determine the location and size of the tumor, but also biopsy can be used to confirm the diagnosis, but for submucosal tumors, biopsy may be negative, should be given Note that the proximal jejunum can be used with a small enteroscopy, and the terminal ileum can be examined with an electronic colonoscopy.
3.B Ultra
For duodenal adenocarcinoma, ultrasound can show the size and location of the tumor, especially for the diagnosis of obstructive jaundice, and can be differentiated from pancreatic head cancer, cholangiocarcinoma, and biliary calculi.
4.CT scan
It is characterized by irregular soft tissue mass, which grows to the inside and outside of the cavity. The enlarged mass is mild to moderately enhanced. The local intestinal wall is irregular or ring-shaped thickening, and the intestinal lumen is narrow. A small number of small intestine adenocarcinomas are only characterized by localized intestinal wall thickening. Sometimes, if there is gas or contrast agent in the necrotic mass, it indicates ulceration, and there is often mesenteric or peritoneal lymph node metastasis. The metastatic lymph nodes are usually not as large as lymph nodes.
5.MRI
It is characterized by obvious thickening of the intestinal wall and soft tissue mass in the intestinal lumen. The intestine is annularly narrow, with a low signal on T1WI and a slightly higher signal on T2WI. The central necrosis is low on T1WI, on T2WI. Significantly high signal, enhanced lesions showed uniform or uneven enhancement after the scan, and the central necrosis was not strengthened.
6. Selective celiac angiography
Gastrointestinal hemorrhage is common in small intestine cancer. The angiography can show abnormal arteries in the lesions. The pathological tumor vascular network has a distinguishing significance for adenocarcinoma, sarcoma and other tumors. It can determine the possibility of surgical resection and understand the abnormalities of blood vessels.
Diagnosis
Diagnosis and diagnosis of small intestinal adenocarcinoma
diagnosis
The clinical manifestations of small intestine adenocarcinoma lack specificity. All patients with chronic abdominal pain over 60 years old, history of gastrointestinal bleeding, recent loss of appetite, weight loss, fatigue, or incomplete intestinal obstruction and anemia should be thought of. Possibly, digestive tract barium examination, endoscopy, etc. can assist in diagnosis, endoscopic forceps biopsy for histopathological examination can confirm the diagnosis, CT, MRI examination can help determine whether there is distal metastasis.
Differential diagnosis
Duodenal ulcer
The disease presents with a typical course of chronic disease, periodic attack and rhythmic upper abdominal pain. X-ray barium meal and endoscopy can confirm the diagnosis.
2.Crohn's disease
It is a gastrointestinal granulomatous inflammatory disease with unknown etiology. The lesions are mostly located in the terminal ileum and adjacent colon. They are often segmental, localized, and jumping. The main clinical manifestations are abdominal pain, diarrhea, abdominal mass, fistula formation and Intestinal obstruction is characterized by fever, anemia, etc. The age of onset is mostly young and middle-aged. It has characteristic X-ray signs: the ileal stenosis at the end of the ileum, the tube wall is stiff and thin, called the line-like sign, and the fiber colonoscopy The residual mucosa of the intestinal wall protrudes from the large ulcer with a paving stone appearance, which is segmental. The intestinal mucosa between the lesions is normal, and the pathological biopsy is non-caseous granulomatous change.
