Tumors of the small intestine Tumors of the small intestine

Unlike the large bowel the small intestine is Unlike the large bowel the small intestine is

rarely the seat of tumors.rarely the seat of tumors.

5% all GIT tumours5% all GIT tumours

1-2 % malignant GIT 1-2 % malignant GIT tumourstumours

Age >50 yr.Age >50 yr.

GIT Neoplasms

There are several theories to explain this There are several theories to explain this fact;fact;

1.1. Rapid transit time decrease the time for Rapid transit time decrease the time for contact of carcinogens with the mucosa.contact of carcinogens with the mucosa.

2.2. The local immune system of the small bowel The local immune system of the small bowel mucosa.mucosa.

3.3. The alkaline pH of the succus entericus.The alkaline pH of the succus entericus.

4.4. The absence of bacteria that might The absence of bacteria that might convert certain ingested products to convert certain ingested products to carcinogens.carcinogens.

5.5. The presence of mucosal enzymes that The presence of mucosal enzymes that destroy certain carcinogens.destroy certain carcinogens.

The symptoms that associated with The symptoms that associated with small bowel neoplasms are often small bowel neoplasms are often vague & they include;vague & they include;

1.1. Epigasteric discomfort.Epigasteric discomfort.2.2. Nausea.Nausea.3.3. Vomiting.Vomiting.4.4. Abdominal pain, which is often Abdominal pain, which is often

intermittent & colicky.intermittent & colicky.5.5. Diarrhea & bleeding.Diarrhea & bleeding.

Diagnosis by : Diagnosis by : barium follow through study, barium follow through study,

CT scan, endoscopy, CT scan, endoscopy, capsule, endoscopy,capsule, endoscopy,

20-25% preoperative diagnosis20-25% preoperative diagnosisIn most of cases diagnosis occur at In most of cases diagnosis occur at

explorative laparotomyexplorative laparotomy

The most common indication for operation in The most common indication for operation in patients with neoplasms of small bowel are patients with neoplasms of small bowel are

obstruction, bleeding & pain. obstruction, bleeding & pain.

Benign tumorsBenign tumors

The most common lesions areThe most common lesions are

adenomas, liomyomas & lipomas, adenomas, liomyomas & lipomas,

other benign tumors includeother benign tumors include

hamartoma, fibromas, hamartoma, fibromas,

angiomas, lymphangiomas, angiomas, lymphangiomas,

Neurofibromas & Neurofibromas & hemangiomas.hemangiomas.

A.A. Benign tumoursBenign tumours more in distal part of small bowel:more in distal part of small bowel: 1.1. Leiomyomas & GIST tumours Leiomyomas & GIST tumours originated from interstial cells of Cajaloriginated from interstial cells of Cajal ( mesodermal in origin ) ( mesodermal in origin )

compose 0f 70 % spindle cell &compose 0f 70 % spindle cell & 30 % epithelial cells30 % epithelial cells

The benign form of these tumours are 3-4 The benign form of these tumours are 3-4 times more common than malignant onetimes more common than malignant one

They express CD 117 in 90 % of cases & They express CD 117 in 90 % of cases & CD 34 in 80 % of casesCD 34 in 80 % of cases

Treatment: local resection.Treatment: local resection.

2. adenomas: 2. adenomas:

3 types:-3 types:-True adenomasTrue adenomas

Villous adenomasVillous adenomasBrunner adenomasBrunner adenomas

Treated by primary resection if they are causing Treated by primary resection if they are causing symptoms except for large villous adenomas symptoms except for large villous adenomas which requires segmental resection.which requires segmental resection.

3. lipomas: treated by simple excision3. lipomas: treated by simple excision

4. Peutz Jegar ( hamartomas )

This is an inherited syndrome & the mode of inheritance is by simple mendalian dominant. seen more frequently in the jejunum & ileum

but the may affect whole the GIT & also extra GIT organs like the ovary, lungs,

breasts & uterus.

It consists of;It consists of; Familial intestinal hamartomatous polyposis Familial intestinal hamartomatous polyposis

where it cause hemorrhage & often where it cause hemorrhage & often intussusception.intussusception.

Melnosis of the oral mucous membrane & the lips.Melnosis of the oral mucous membrane & the lips.

Histology; Histology;

the polyps can be likened to trees & consist of the polyps can be likened to trees & consist of smooth muscle fibers & covered by normal smooth muscle fibers & covered by normal mucosa.mucosa.

Treatment ;Treatment ;

by segmental resection of severely involved by segmental resection of severely involved segment only.segment only.

5.5. haemangiomas : they are multiple in 60% of cases but haemangiomas : they are multiple in 60% of cases but most common site is the jejunum. In cases of bleeding most common site is the jejunum. In cases of bleeding the treatment is by segmental resection.the treatment is by segmental resection.

B. malignant small bowel B. malignant small bowel tumours:tumours:

1. adenocarcinoma 50%1. adenocarcinoma 50%

2. carcinoid tuomur2. carcinoid tuomur

3. malignant GIST 20%3. malignant GIST 20%

4. lymphomas 7-25%4. lymphomas 7-25%

Adenocarcinoma Adenocarcinoma more in duodenum & jejunum,more in duodenum & jejunum, and it usually late in diagnosis.and it usually late in diagnosis.

Occurring in carcinoma age group,Occurring in carcinoma age group, prognosis depends on the stage of disease.prognosis depends on the stage of disease.

Malignant GISTMalignant GIST more in jejunum & ileum more in jejunum & ileum spread by direct invasion & by hematogenous spread by direct invasion & by hematogenous

wayway to liver ,lungs & bone.to liver ,lungs & bone.

Prognosis depends on stage & grade of disease.Prognosis depends on stage & grade of disease.

Lymphomas more in ileum,

occurring at younger age group & seen more in patients with celiac disease & AIDS.

Treatment of adenocarcinoma & lymphoma

by:

1. wide local excision if not possible.

2. palliative resection if not possible 3. bypass operations

Treatment of malignant GIST tumours by Segment a resection with wide

margin & if possible resection of liver metastasis.

Chemotherapy & radiotherapy are of little role in adenocarcinoma but are helpful in lymphoma cases and Imatinib is useful in malignant GIST.

Prognosis : > 50% had metastasis at laparotomy,

5 yrs survival is < 25%.

3- carcinoid tumor; (25%)3- carcinoid tumor; (25%) These tumors occur throughout the GIT These tumors occur throughout the GIT & also in the bronchus, testis & also in the bronchus, testis

& ovary. & ovary.

The appendix is the commonest site The appendix is the commonest site involved (65%)involved (65%)

followed by the ileum (25%).followed by the ileum (25%).

These tumors arise in the cells ofThese tumors arise in the cells of kulchitskykulchitsky at the base of the crypts of at the base of the crypts of

lieberkuhn, lieberkuhn, when metastasis occurs to the liver the disease when metastasis occurs to the liver the disease

is calledis called

carcinoid syndromecarcinoid syndrome..

The tumor produces 5HT (serotonin) which might be present as 5- hydroxt indol acetic acid in the urine during the attacks.

Also it may produce kinins, PGs, kallikrin, substance P, neurotrophin , chromogranin A>90%, Hstamin &

Dopamin. The clinical syndrome consists of reddish-blue cyanosis, flushing attacks, diarrhea, borborygmi, asthmatic attacks & eventually

some times pulmonary & tricuspid valves stenosis.

Classically the flushing attacks are induced by alcohol.

Diagnosis by : estimation of 5HIAA in 24 hrs urine chromogranin A provocative test ( clinical test ) by giving

patient pentagasterin calcium, epinephrine.

Treatment;Treatment;Tumor < 1 cm ------ local resectionWhen small lesions discovered at appendectomy, removal of the

appendix is the sufficient treatment.Tumors > 1cm & bigger + LNs involvement ------ wide

resection Eg : terminal ileum ---- Rt hemicolectomy

Liver secondaries are Treated accordingly :

Segmentectomy or lobectomy s.t liver transplantation ??

+ medical treatment by somatostatin ( Octeriotide ) + antihistamins

& alpha methyldopa & steroids . might help to reduce the

severity of the attacks.

Prognosis :Prognosis : most better than other small intestinal most better than other small intestinal

malignanciesmalignancies Small tumors has 100% 5 years survival rateSmall tumors has 100% 5 years survival rate Regional disease 65% 5years Regional disease 65% 5years

survival ratesurvival rate Distant metastasis 25 – 35 % 5 years Distant metastasis 25 – 35 % 5 years

survival ratesurvival rate

Metastatic neoplasm : Metastatic neoplasm :

is the most common small bowel tumor reaching is the most common small bowel tumor reaching them from them from

direct extension or direct extension or by implantation or by implantation or from extra-abdominal tumors; from extra-abdominal tumors;

lungs, breast, lungs, breast, & more common from melanoma.& more common from melanoma.

Treatment:Treatment: local resection or bypass to relieve local resection or bypass to relieve

obstruction.obstruction.