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Small bowel tumors. Dr. TAMERM. ABD ELRHMAN. Risk factors. Red meat, Ingestion of smoked or cured foods. Crohn’s dsease . Hereditary nonpolyposis colorectal cancer . Familial adenomatous polyposis (FAD) – 100% to develop duodenal CA. Peutz-Jeghers syndrome. Symptoms.

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small bowel tumors

Small bowel tumors

Dr. TAMERM. ABD ELRHMAN

risk factors
Risk factors
  • Red meat, Ingestion of smoked or cured foods.
  • Crohn’sdsease.
  • Hereditary nonpolyposis colorectal cancer.
  • Familial adenomatouspolyposis (FAD) – 100% to develop duodenal CA.
  • Peutz-Jegherssyndrome.
symptoms
Symptoms
  • Most are asymptomatic.
  • Symptoms:
  • Vague abdominal pain(with N/V, diarrhea).
  • Bleeding.
  • Obstruction (intussuception, circumferencial growth, kinking of the bowel, intramural growth).
diagnosis
Diagnosis
  • For most are asymptomatic it is rarely diagnosed preoperatively.
  • Serological examination:
    • Serum 5-hydroxyindole acetic acid (HIAA) for carcinoid.
  • Radiological examination:
    • Enteroclysis (test of choice – 90% sensitivity).
    • CT scan.
    • Angiography --> bleeding lesions.
  • Endoscopy.
benign tumors
Benign tumors

Adenomas: (most common benign neoplasm – duodenum): tubular, villous, tubulovillous.

Fibromas, lipomas, hemangiomas, lymphangiomas, neurofibromas.

peutz jeghers syndrome
Peutz-Jeghers Syndrome
  • Inherited syndrome of:
    • Mucocutaneousmelatonic pigmentation (face, buccal mucosa, palm, sole, peri-anal area).
    • Gastrointestinal polyp(jejunum and ileum are most frequent part followed by colon, rectum and stomach).
  • Symptoms:
    • colicky abd.pain (due to intermittent intussuception).
    • Hemorrhage.
  • Treatment:
    • Segmental resection of the bowel causing obstruction or bleeding.
    • Cure impossible due to widespread intestinal involvement
malignant neoplasm1
Malignant neoplasm:
  • Adenocarcinoma:
    • Most common CA of small bowel.
    • Most common in duodenum and proximal jejunum.
    • Half involve the ampulla of Vater.
  • Carcinoid:
    • Appendix (46%) > Ileum (28%) > Rectum (17%)
    • Aggressive behavior than the appendicealcarcinoid.
      • appendix – 3% metastasize; Ileum – 35% metastasize
      • Appendix – solitary; Ileum – 30% multiple.
carcinoid syndrome
carcinoid syndrome
  • 25-50% with carcinoid tumor with liver metastasis develops carcinoid syndrome.
    • Secretes serotonin, bradykinin and substance P, (which undergo complete metabolism inliver, so symptoms of carcinoid syndrome is rare in absences of liver metastasis).
      • Diarrhea
      • Flushing
      • Hypotension
      • tachycardia
      • fibrosis of endocardium and valves of the right heart.
malignant neoplasm2
Malignant neoplasm:
  • Lymphomas:
    • Most common intestinal neoplasm in children under 10y/o.
    • Most common presentation: obstruction, Perforation.
    • Criteria of primary lymphomas of the small bowel:
        • Absence of peripheral lymphadenopathy.
        • No evidence of mediastinal LN enlargement.
        • Normal WBC count.
        • At operation, bowel lesion must predominate the only nodes are associated with the bowel lesion.
        • Absence of disease in the liver and spleen.
malignant neoplasm3
Malignant neoplasm:
  • GISTs: (gastrointestinal stromal tumors)
    • Most common mesenchymal tumors arising in the small bowel.
    • 70% arises from the stomach followed by the small bowel.
    • Associated with overt hemorrhage.
    • Has its expression of the receptor tyrosine kinaseKIT (CD117).
treatment
Treatment:
  • Benign lesions:
    • All symptomatic benign tumors should be surgically resected or removed endoscopically.
      • Duodenal adenomas with FAP should undergo panareaticoduodenectomy (it has 100% degenerate to CA).
treatment1
Treatment:
  • Malignant lesions:
    • Adenocarcinoma:
      • Wide local resection with it’s mesentery to achieve regional lymphadenectomy.
      • Chemotherapy has no proven efficacy in the adjuvant or palliative treatment.
    • Small intestinal lymphoma:
      • For localized: segmental resection with adjacent mesentery.
      • If with diffused involvement: -->chemotherapy is primary therapy.
treatment2
Treatment:
  • Carcinoid:
    • Segmental intestinal resection & regional lymphadenectomy.
    • 30% are multiple, hence entire small bowel should be examined prior to surgery.
    • If with metastatic lesions---> debulking.
    • Chemotherapy: ---> 30-50% response

( Doxorubicin, 5-fluorouracil. Streptozocin).

    • Octreotide: - most effective for management of symptoms of carcinoidsyndrome.
treatment3
Treatment:
  • Small-intestine GISTs:
    • Segmental resection.
    • If was preoperatively diagnosed, lymphadenectomy not be done,as rarely associated with LN metastases.
    • Resistant to conventional chemotherapy.
    • IMATINIB (Gleevec): tyrosine kinase inhibitor
      • Clinical trial show 80% of pt with unresectable lesions or metastasis showed clinical benefits, 50 – 60% showed evidence of reduction in tumor volume.