metastatic small bowel tumor
Introduction
Introduction to metastatic small bowel tumors Metastatic small intestine tumors are rare in clinical practice and often occur in patients with advanced or extensive metastasis of malignant tumors, especially those from other digestive tract malignancies. Malignant tumors can invade the small intestine through blood, lymph, and intraperitoneal implantation. Especially in the blood line and intra-abdominal planting is more common. Malignant melanoma often undergoes blood transfer, and squamous cell carcinoma and adenocarcinoma often undergo lymphatic metastasis. basic knowledge The proportion of the disease: the disease is rare, the incidence rate is about 0.001% Susceptible people: no specific population Mode of infection: non-infectious Complications: intestinal obstruction peritonitis
Cause
Metastatic small bowel tumor etiology
(1) Causes of the disease
The primary lesion of small intestinal metastases can be derived from cervical cancer, malignant melanoma, colorectal cancer, ovarian cancer, kidney cancer, stomach cancer, lung cancer and skin cancer.
Metastases are more common in the ileum, especially in the terminal ileum, followed by the jejunum. The duodenum is less common. It can be single (such as adenocarcinoma) or multiple (such as malignant melanoma), and both squamous cell carcinoma can be seen. The size of the metastases is 0.5 to 12 cm, with an average of 3 to 5 cm. The tumor invades the intestinal wall, the surface ulcers, the central necrosis is acute, and the chronic perforation; or the intestinal obstruction due to stenosis, intussusception, torsion, adhesion, infiltration, etc. Lymph nodes are 40% involved, histological classification is mostly adenocarcinoma and squamous cell carcinoma, followed by malignant melanoma.
(two) pathogenesis
Malignant tumors can be invaded into the small intestine through blood, lymph, and intra-abdominal implantation, especially in blood and intra-abdominal implantation. Malignant melanoma is often metastasized by blood, and squamous cell carcinoma and adenocarcinoma are lymphatic metastasis.
1. Hematogenous metastasis: Hayes emphasizes the vertebral venous approach. This vein has no valve, communicates with the renal vein, portal vein and surrounding circulation. The increase of abdominal pressure causes the tumor thrombus to be released, and enters the circulation through the lung, portal or vena cava, with melanoma and Lung cancer is common, followed by colon cancer, other gastrointestinal cancer, ovarian cancer, cervical cancer and breast cancer.
2. Lymphatic metastasis: Lymphatic metastasis of abdominal organ malignant tumors, often according to the anatomical location, the lymphatic vessels of the right colon are all connected to the upper mesenteric lymph nodes, closely related to the upper edge of the duodenal horizontal segment, so right If lymphatic metastasis occurs in a semi-colon malignant lesion, metastases appear on the upper edge of the duodenal horizontal segment, and most of the lymphatic vessels in the left colon are introduced into the inferior mesenteric lymph node, which is closely related to the ascending part of the duodenum. Lymphatic metastasis of malignant lesions of the left colon can cause nodular impressions in the duodenal ascending or duodenal jejunum. The lymphatic metastasis is often blocked by lymphatic drainage and caused by lymphatic reflux in the abdominal cavity.
3. Planting transfer: Planting metastasis includes planting after surgery, males are mostly from the gastrointestinal tract, and women are from ovarian malignant tumors.
Prevention
Metastatic small bowel cancer 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.
Complication
Metastatic small bowel tumor complications Complications, intestinal obstruction, peritonitis
1. Intestinal obstruction: It is one of the common complications. At the beginning, the intestine is infiltrated by the tumor or the intestine is compressed, causing intestinal stenosis, which is characterized by chronic incomplete intestinal obstruction.
2. Bleeding: Black stool can be seen when a large amount of bleeding occurs, and the tar is like.
3. Intestinal perforation and peritonitis: Most of the intestinal perforation develops into intestinal perforation, partly due to tumor necrosis, ulceration, infection and perforation.
Symptom
Metastatic small bowel tumor symptoms Common symptoms cachexia high fever intestinal perforation low intestinal obstruction nausea low heat dull pain bloating
The primary tumor has been surgically resected or controlled by treatment, but it can also be concealed and found at the same time as the metastases. The onset is often sudden, and the clinical symptoms are mostly partial intestinal obstruction until complete intestinal obstruction. Most of them are complete intestinal obstruction or perforation, subacute patients often have bleeding, and chronic ones have partial intestinal obstruction.
1. Abdominal pain: It is the most common symptom. About 80% of patients may have different degrees of abdominal pain. It is one of the main reasons for the treatment. The abdominal pain is mostly located in the middle and lower abdomen and the umbilicus. It can also be seen in the upper abdomen. The abdominal pain is initially blunt. Pain, dull pain or pain, increased after a meal, often accompanied by bowel sounds, with the development of the disease, to the late stage due to tumor infiltration of the intestine to complete blockage, intussusception, intestinal torsion leading to complete intestinal obstruction, the patient appears persistently severe Colic, paroxysmal aggravation, and abdominal distension, nausea and vomiting, stop anal exhaust defecation, etc., often require emergency surgery to remove the obstruction.
2. Intestinal obstruction: It is one of the common complications. At the beginning, the tumor is infiltrated by the intestine or the intestine is compressed, causing intestinal stenosis, which is characterized by chronic incomplete intestinal obstruction. When the disease is long, the patient can see the ups and downs. The gastrointestinal type and peristaltic wave, sometimes consciously sometimes scattered in the intestines in the abdomen swimming, and have a sense of suffocation, intestinal obstruction and tumor infiltration growth mode: the tumor infiltrates along the horizontal axis of the intestine, showing a circular stenosis, Intestinal tube shrinkage, stenosis and intestinal obstruction, obstruction symptoms are not easy to alleviate; tumor infiltrating intestine and extraintestinal retina, mesangium, lymph nodes and adhesions form a mass, causing adhesive intestinal obstruction; tumor body nested into the intestine, resulting in intussusception If the tumor is reset, the obstructive symptoms can be alleviated or alleviated.
3. Diarrhea: About 1/3 of the patients have diarrhea symptoms, which are caused by malabsorption of the intestines or extensive intestinal involvement. At the beginning of the disease, the stool is mushy, 4 to 5 times a day, no obvious mucus and pus Blood, as the disease progresses, the number of stools increases and mucus increases.
4. Bleeding: more common, generally manifested as fecal occult blood positive, a large amount of bleeding can be seen in the black stool, tar-like stool, bleeding is mainly due to tumor surface erosion, ulcers, necrosis.
5. Abdominal mass: About 1/3 of the patients in the clinic can touch the abdominal mass, the size is different, the small ones are several centimeters, the larger ones are more than 10 centimeters, the shape is irregular, there is nodular feeling, mild tenderness, in The initial mass of the disease can be promoted, and as the disease progresses, the activity gradually decreases, and finally it is completely fixed.
6. Intestinal perforation and peritonitis: more on the basis of intestinal obstruction to develop intestinal perforation, partly due to tumor necrosis, ulceration, infection and perforation, acute perforation can cause diffuse peritonitis, the mortality rate is extremely high; chronic can occur Adhesive adhesions, abscesses, intestinal fistulas, etc.
7. Others: Some cases may have fever, mostly low fever, high fever is rare, may have fatigue, anemia, anorexia, abdominal distension, weight loss and jaundice, etc., late stage due to tumor consumption, diarrhea, patients eating less and appear cachexia.
Examine
Examination of metastatic small intestine tumors
Blood routine examination can show anemia, erythrocyte sedimentation rate can be increased, and fecal occult blood can be positive.
1. X-ray examination: The gas-liquid plane can be seen in the abdominal fluoroscopy, and the soft tissue block shadow can also be seen in the abdominal plain film. The double-contrast contrast examination of the small intestine gas sputum has important value for detecting the small intestinal metastasis. The specific performance can be:
(1) Localized concentric stenosis, mucosal destruction, wrinkles disappear, and the intestinal wall is smooth and stiff.
(2) Isolated bulging lesions, filling defects.
(3) ulcer formation, irregular large shadow, often accompanied by mild stenosis and nodular lesions.
(4) The fistula is formed and the expectorant overflows.
(5) Freezing signs, seen in extensive abdominal metastasis and malignant diffuse peritoneal mesothelioma.
(6) multiple nodular-like intestinal wall impression, visible signs of intestinal obstruction, occasional pneumoperitoneum.
2. B-ultrasound and CT: B-ultrasound and CT are easy to find the size, location, depth of invasion and relationship with surrounding tissues, and the primary tumor can be found. The tumor diameter can be more than 2cm, and the CT can be scanned by oral contrast agent. Can display intestinal irregularities, destruction, shadow and sinus, and can clearly show extraintestinal metastases and lymph node metastasis.
3. Selective mesenteric angiography: It is helpful for the diagnosis of small intestine metastatic tumors, and has a high value for improving the detection rate and localization diagnosis of small intestinal metastases, especially for patients with tumors associated with hemorrhage. The positive rate of the method is >90%, and its performance is as follows:
(1) Tumor infiltration and vascularization.
(2) Tumor neovascularization.
(3) The cystic changes and necrotic areas of the tumor are filled with contrast agent, which is "lake", "pool", or "sinus".
(4) Tumor wrapping causes stenosis and obstruction of blood vessels.
(5) The capillary perfusion time is prolonged or the permeability is increased, and tumor staining occurs.
(6) Arteriovenous shunt, early filling of veins.
4. Fiber endoscopy: It is helpful for duodenal metastases. Colonoscopy can be used for the proximal jejunum and colonoscopy for the distal ileum.
5. Laparoscopy: Abdominal lesions can be visually detected, and biopsy can be diagnosed, but it is an invasive examination, which is expensive and clinically less useful.
Diagnosis
Diagnosis and differentiation of metastatic small intestine tumor
diagnosis
1. The clinical diagnostic criteria for metastatic small bowel tumors should be:
(1) The location of the primary malignant tumor must be clarified.
(2) clinical manifestations suggest the symptoms and signs of small bowel lesions, such as obstruction, perforation, bleeding and so on.
(3) Confirmed by laparotomy or specific examination.
(4) Determined by histology.
(5) Metastatic small intestine tumors are not caused by diffuse abdominal invasion or extensive metastasis.
(6) Small intestine metastases are not directly invaded by the primary tumor.
2. Clinical manifestations.
3. Laboratory and other auxiliary inspections.
Differential diagnosis
1. Duodenal ulcer: abdominal pain, gastrointestinal bleeding, nausea, vomiting, abdominal distension and other symptoms may occur, in addition to the above symptoms can also cause pyloric obstruction symptoms, need to be differentiated from duodenal tumor, by X-ray examination, Arterial angiography, duodenal microscopy plus histological examination can be distinguished, if necessary, surgical exploration is required to confirm the diagnosis.
2. Chronic bacterial dysentery: acute bacillary dysentery can be cured to chronic, and can also be acute on the basis of chronic, manifested as 3 to 5 times a day stool, may be accompanied by mucus, pus and blood, and more urgency A small number of patients have pain in the left lower abdomen. The positive rate of stool culture in chronic bacillary dysentery is low, generally only 15% to 30%. Therefore, pathogens should be found after repeated cultures.
