Signs and symptoms of small intestine cancer. Small Intestine Cancer: Signs and Symptoms at Different Stages Small Intestine Loop Cancer Treatment Methods

Malignant tumors of the small intestine are a rare disease, accounting for approximately 1% of all malignant tumors of the gastrointestinal tract.

Unfortunately, the diagnosis is established in the later stages, when surgery is almost impossible. The reason for late diagnosis is the difficulty of instrumental examination of the small intestine, as well as the absence of specific symptoms, which leads to a late visit of the patient to the doctor.

The small intestine occupies most of the abdominal cavity and is located there in the form of loops. Its length reaches 4.5 m. The small intestine is divided into the duodenum, jejunum and ileum. Cancer can develop in any part of the small intestine. Most often, cancer affects the duodenum.

Causes of small intestinal tumors

More frequent damage to the duodenum is due to the irritating effect of bile and pancreatic juice on the initial section of the small intestine, as well as its active contact with carcinogens that enter the digestive tract with food.

Other causes may be smoking, alcohol abuse, fried foods, as well as oncological diseases of other organs that metastasize to the tissues of the small intestine.

Types of small bowel cancer

• Adenocarcinoma.
• Mucous adenocarcinoma.
• Signet ring cell carcinoma.
• Undifferentiated and unclassified cancer.

Stages of development of small intestine cancer

Stage 1. The cancerous tumor does not extend beyond the walls of the small intestine, does not penetrate other organs, and does not metastasize.

Stage 2. The cancer tumor extends beyond the walls of the small intestine and begins to grow into neighboring organs, but has not yet metastasized.

Stage 3. The cancer has metastasized to several lymph nodes near the small intestine, but has not yet metastasized to distant organs.

Stage 4. A cancerous tumor of the small intestine has metastasized to distant organs (liver, lungs, bones, etc.).

Symptoms of small intestine cancer

The clinical picture of duodenal cancer resembles gastric and duodenal ulcers, but aversion to food is characteristic. Most often, a symptom of cancer in this department is dull pain in the epigastric region. Irradiation of pain to the back is typical. Late symptoms (jaundice, nausea and vomiting) are associated with an increase in bile duct obstruction and closure of the intestinal lumen by a tumor.

The clinical picture of cancer of the jejunum and ileum consists of local symptoms and general disorders. The most common initial symptoms are dyspeptic disorders - nausea, vomiting, bloating, cramping pain in the intestines, navel or epigastrium. Subsequently, a decrease in body weight is observed, which may be associated with both reduced nutrition and rapid tumor growth. Frequent loose stools with a lot of mucus and spasms are also among the early symptoms.

Intestinal obstruction is a complex of symptoms characteristic of varying degrees of intestinal obstruction, observed in most patients with small intestinal tumors.

Often, small intestinal cancer is accompanied by obvious or hidden blood loss.

Symptoms of general disorders include increasing weakness, weight loss, malaise, weakness, fatigue, and anemia.

A complication of small intestinal cancer is metastases to the retroperitoneal lymph nodes, distant metastases are observed in the liver and ovaries.

Diagnosis of small intestine cancer

• Angiography of abdominal vessels.
• Laparoscopy.
• CT scan.
• Magnetic resonance imaging.
• A biopsy to determine the type of cells and their degree of malignancy.
• Electrogastroenterography– allows you to identify disorders of small intestinal motility, which often occur with malignant neoplasms in this part of the intestine.

Treatment of small intestine cancer

In some cases, the operation is palliative in nature, that is, it is carried out only to alleviate the suffering of the patient.

If surgery is not possible or if there is a tumor that is sensitive to chemotherapy, therapy is used using drugs that suppress the growth and prevent the development of tumor cells.

In the postoperative period, it is important not to miss a dangerous complication - intestinal paresis. To do this, it is necessary to diagnose intestinal motility using electrogastroenterography .

Doctors classify malignant neoplasms of the small intestine as C17 in the International Classification of Diseases ICD-10.

Professional articles related to small bowel cancer:

Firsova L.D., Masharova A.A., Bordin D.S., Yanova O.B. Diseases of the stomach and duodenum // – M: Planida. – 2011. – 52 S.

Small intestinal cancer affects its sections, which include the duodenum, ileum, and jejunum. The disease is diagnosed quite rarely, in 1% of cases of the total number of gastrointestinal cancers. Mostly male patients aged 60 years or more are predisposed to it.

At the initial stage, the disease occurs without severe symptoms. In this regard, many patients seek medical help already in the most advanced stage. First of all, this threatens metastasis and, as a consequence, secondary oncology.

Causes of the disease and its varieties

Among the reasons for the development of oncology are:

• chronic diseases of the gastrointestinal tract;
• benign intestinal neoplasms and inflammation;
• malignant tumors located in other organs;
• Peutz-Jeghers syndrome and genetic abnormalities;
• nicotine addiction and alcoholism;
• frequent consumption of “heavy” foods;
• consequences of radioactive radiation.

Experts believe that not the least important reason is a hereditary predisposition to cancer.

There are several types of intestinal tumors. Among these are adenocarcinoma (the tumor is covered with ulcers and has a fleecy surface), carcinoid (mainly localized in the appendix or ileum), leiomyosarcoma (one of the largest tumors, determined by palpation even through the peritoneal walls), lymphoma (the rarest tumor that combines signs of lymphosarcoma and diseases of lymphoid tissue).

Symptoms and stages

At the beginning of the disease, there are no obvious signs of small intestinal cancer. Phenomena such as nausea, periodic cramps and heaviness in the abdomen, heartburn, flatulence and stool disorders, irritability and general weakness rarely cause severe concern.

The manifestation of symptoms of oncology becomes obvious already at stages 3 or 4. Common symptoms of small intestine cancer include:

• intestinal obstruction;
• bleeding and damage to the intestinal walls;
• formation of ulcers and fistulas;
• disturbances in the functioning of the liver and pancreas;
• pain during bowel movements;
• general intoxication and accelerated weight loss;
• lack of iron in the body.

Mostly, small intestine cancer occurs in the same way in both sexes. Additional signs of intestinal cancer in women include pale skin, menstrual irregularities and discomfort during urination.

Typical stages of disease development:

• Stage 0

The onset of oncology is indicated by a few accumulations of atypical cells, their active degeneration and division. The onset of the disease at this stage can only be determined by examining the composition of the blood.

• Stage 1

Characteristic is the location of the tumor within the small intestine and the absence of metastases.

• Stage 2

The tumor can penetrate beyond the boundaries of the intestine and affect other organs. Metastases are not detected at this stage of the disease.

• Stage 3

Metastases are found in nearby lymph nodes and organs. There is no distant metastasis yet.

• Stage 4

Metastases penetrate through the lymphatic system to distant organs. Oncology can be found in the bones, adrenal glands, bladder, liver, pancreas, lungs, etc.

In rare cases, during the development of the disease, discomfort during swallowing food, a feeling of the presence of a foreign body in the abdominal cavity, and a false urge to defecate are noted. In each specific case, the symptoms of small intestine cancer are not the same and are determined by the influence of various factors.

Diagnosis and treatment methods for oncology

Diagnosis of small intestinal cancer is carried out using fibrogastroduodenoscopy and contrast fluoroscopy. Doctors can resort to irrigoscopy to identify tumors in the ileum.

No less important in the process of diagnosing the disease is radiography of the barium passage. Selective angiography of the abdominal organs can provide significant benefits for the correct diagnosis and further treatment of cancer.

The ultrasound method significantly helps to identify metastases and the degree of their development in other organs. To do this, the condition of the internal organs most susceptible to metastasis is carefully examined. Chest radiography, multislice computed tomography of the abdominal cavity (MSCT), and radiological bone diagnostics (scintigraphy) are performed. To clarify some data, diagnostic methods such as laparoscopy or irrigography may be indicated.

Enough attention is paid to the differential diagnosis of the disease. It is important to determine in time the differences between cancer and benign tumors, intestinal tuberculosis, obstruction of mesenteric vessels, Crohn's disease, kidney dystopia, and retroperitoneal tumors. Among female patients, special attention is paid to differentiating cancer from tumors of the internal reproductive organs, congenital small intestinal stasis and colon oncology.

Treatment of small intestinal cancer is complex and requires radical techniques. For this reason, it is often difficult for patients to tolerate. The main methods include:

• surgical intervention;
• drug treatment;
• radiation therapy.

The most effective and frequently used method of treating the disease remains surgery. Resection, or removal of the affected area, can provide the best and most long-lasting results.

Traditionally, two types of surgical intervention are distinguished:

• radical (the main goal is complete removal of the source of the lesion, including the problem area and the affected tissue adjacent to it);
• palliative procedures (designed to alleviate the patient’s condition and improve the overall quality of his life).

The structure of the organ allows for radical action to remove a tumor that has spread to healthy tissue. Effective treatment methods include transplantation of donor intestinal fragments.

Drug treatment is used in situations where the tumor cannot be removed or is highly sensitive to the effects of chemicals. During chemotherapy, powerful toxins are introduced into the body, aimed at destructive effects on tumor cells. A significant disadvantage of this type of treatment for the disease is its severe course and the development of numerous side effects (death of cells of healthy organs, hair loss, weakened immunity, dyspeptic disorders).

Radiation therapy is an additional method of treating the disease, used to enhance the postoperative effect and course of chemotherapy. The procedure is carried out using special emitting devices. As a result, radiation-sensitive tumor cells are destroyed.

The method does not pose a significant danger to healthy cells of the body, since they have greater resistance to radioactive radiation and are able to effectively withstand it.

Traditional methods of fighting the disease

There is no doubt that small intestine cancer requires the mandatory assistance of qualified specialists and effective treatment methods. The use of traditional methods can play the role of an auxiliary stage aimed at overall strengthening the body and minimizing the manifestations of symptoms of the disease.

Traditional healers offer a variety of recipes to alleviate the condition of people diagnosed with cancer.

Recipe No. 1

It is recommended to use tincture from the pericarp of ordinary walnuts as an effective immunomodulator. To do this you will need 25 nuts and 2 liters of sugar syrup. All ingredients must be mixed, left for at least 3 days and taken two tablespoons daily before meals.

Recipe No. 2

An infusion of calamus root is useful. To prepare it, 30 grams of crushed raw materials must be brewed in 1 liter of boiling water. The warm infusion is taken every morning in small portions.

Recipe No. 3

No less effective is a decoction of buckthorn and chamomile in a ratio of 2 to 1. The mixture of herbs is poured with boiling water and simmered for 10 minutes over low heat. The finished product is taken up to 3 times a day after meals.

Recipe No. 4

Drinking fresh cabbage and pumpkin juice for a month can support the body during illness and treatment of oncology with aggressive chemicals. You must take at least half a glass of natural drink per day.

Such simple recipes can significantly strengthen the immune system and ease the course of the disease.

Prognosis and prevention

A favorable prognosis significantly depends on the period of contact with a medical institution, as well as the stage of development of the disease. Timely diagnosis of a tumor and surgery to remove it significantly increases the likelihood of a complete cure for the patient from cancer.

After surgical intervention at the earliest possible stage, pathological processes are eliminated for a long time. The main postoperative effect is secured by adequate chemotherapy. As a result, the chances of a favorable prognosis for the outcome of the disease increase significantly.

A simple set of preventive measures will help prevent small intestinal cancer. The following should be relevant:

• active lifestyle and giving up bad habits;
• minimizing stress, nervous exhaustion and physical fatigue;
• the presence in the diet of plant foods with a high level of coarse fiber;
• minimizing the consumption of foods containing animal fats;
• visit a gastroenterologist at the slightest suspicion of manifestations of the disease;
• regular visits to a gastroenterologist after 40 years.

Small intestinal cancer belongs to those forms of oncology that, with timely detection and a serious approach to treatment, can be eliminated forever. A considerable number of patients who have undergone an effective course of treatment for the disease continue to live full lives for many years.

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The small intestine makes up 75% of the length of the gastrointestinal tract and more than 90% of the mucosal area, but tumors are rare. It is difficult to judge the true incidence of small intestinal tumors based on the few publications in the world literature.

Generalized data indicate that tumors of the small intestine account for 1-6% of all tumors of the gastrointestinal tract and 2-6.5% of intestinal tumors. Malignant tumors of the small intestine account for no more than 1% of all malignant tumors of the gastrointestinal tract or 0.4-0.8 per 100,000 population.

Malignant tumors of the small intestine are 40-60 times less common than those in the colon. In the small intestine, the predominant forms of malignant tumors are adenocarcinoma, leukomyosarcoma, malignant lymphoma and carcinoids.

Statistics from recent years indicate that the frequency of cancer and sarcoma in relation to all malignant tumors of the gastrointestinal tract is comparable and is about 1%, or even a higher proportion of cancer is noted.

Benign tumors are most often localized in the ileum, less often in the small intestine (Fig. 1). Mostly they are solitary. They can grow both into the lumen of the organ and outward. Tumors mainly grow inward, coming from the mucous membrane, submucosal and internal muscular layers, and outward - arising from the outer muscular and subserous layers.

Rice. 1 Localization of tumors of the small intestine. C - sarcoma; R - cancer; K - carcinoid; D - benign tumors.

The most characteristic of benign tumors is growth in the form of a node. The node is often located on a broad base, less often it has a stalk, which is more typical for adenomatous polyps.

According to histological structure, benign tumors are most often represented by leiomyomas. They can arise from both the inner and outer muscle layers. About 15-20% of leiomyomas become malignant. Fibromas usually grow into the intestinal lumen and often have a mixed structure in the form of fibrolipomas, phobromyxomas, and phobroadenomas.

Lipomas can originate from the submucosal layer (internal lipomas) and from subserous fatty tissue (external lipomas). They are more common in obese people and can be combined with lipomas of other locations.

Hemangiomas grow from the submucosal layer and, as a rule, into the intestinal lumen. They are often multiple. There are cavernous, capillary angiomas and telangiectasias. There are known cases of multiple hemangiomas of the gastrointestinal tract.

Adenomas or adenomatous polyps occupy a special place among benign tumors. They can be either single or multiple. Basically, they come from the glandular elements of the mucous membrane.

These are true adenomatous polyps. But polyps can also arise from other tissues of the intestinal wall, in particular, the submucosal layer - fibrous vascular polyps. Often, polyps of the small intestine are combined with polyps of other locations.

Some specific variants of multiple polyposis of the gastrointestinal tract are identified into separate forms, in which the small intestine can also be affected. This is Peutz-Jeghers syndrome, as well as Cronkhite-Canede syndrome, characterized by the presence of stomach polyps and polyposis changes in the intestines, combined with proteinuria, skin pigmentation, changes in the nails of the hands and feet.

One of the rare ones is Turcot's syndrome or glial polyposis syndrome, manifested by a combination of intestinal polyposis and a brain tumor (usually glioma).

There is no consensus regarding the malignant transformation of small intestinal polyps. Most authors deny it, which is supported by the histological structure of polyps, the long life span of patients without signs of malignancy (up to 30 years), and the lack of correspondence between the localization of polyps and malignant tumors.

Adenocarcinoma is the most common form of cancer and malignant tumors of the small intestine in general, accounting for up to 70%. In addition, solid cancer and poorly differentiated forms of cancer also occur. More often, cancer is localized in the jejunum, where it appears in the form of an extensive polypoid tumor or an infiltrating ring-shaped narrowing of the intestine.

As a rule, cancerous tumors of the small intestine are single, although primary multiple forms have been described. Stenosing annular cancer narrows the intestinal lumen. Proximal to the bowel is dilated. Nodular polypoid tumors can also cause intestinal obstruction and intestinal obstruction.

In addition, a small tumor can cause intussusception. Fixation of the affected loop to the anterior abdominal wall is often observed. Metastasis of small intestinal cancer occurs by lymphogenous, hematogenous and implantation routes.

In 50% of patients, metastases are found in regional mesenteric lymph nodes. Distant metastases affect the retroperitoneal lymph nodes, liver, ovaries, greater omentum, bones, and lungs. Implantation metastasis occurs both in the intestinal lumen and in the peritoneum.

The most common type of sarcoma in the small intestine is leiomyosarcoma. It develops from the muscle fibers of the intestinal wall. It is localized equally often in all parts of the small intestine. Macroscopically, the tumor has the shape of a node, reaching 15-20 cm. Infiltrating growth is not always obvious.

The cut surface is mottled, due to the presence of foci of hemorrhage, necrosis and tissue melting. Obstruction of the intestine, as a rule, develops with large tumor sizes or with a pronounced infiltrative process.

Leiomyosarcoma is more characterized by ulceration and disintegration, which leads to severe bleeding. The same complication is typical for neurosarcomas, which, due to frequent necrosis, often lead to perforation of the intestinal wall.

Malignant lymphomas or lymphosarcoma are a rarer form, accounting for 6-8%, and according to some authors - up to 16%. The most common type of malignant lymphoma of the small intestine is lymphosarcoma; reticulosarcoma and giant cell lymphoma are less common.

These tumors are observed at any age, somewhat more often in men. Macroscopically, all malignant lymphomas are represented by single or merging multiple nodes, massive conglomerates or a continuous infiltrate.

Based on the histological structure, there are medullary (nodular) type and diffuse type, in which the tumor tissue evenly infiltrates the intestinal wall. Lymphosarcoma can grow extraintestinal and less commonly endointestinal.

They are prone to early metastasis, which occurs mainly lymphogenously. During development and growth, they can cause obstructive intestinal obstruction, perforation of the intestinal wall, and massive intestinal bleeding.

Clinical symptoms.

As a rule, malignant tumors have certain clinical symptoms. Only 5% of tumors are completely asymptomatic. At the same time, the absence of clinically significant symptoms is typical for small benign tumors. Tumors localized in the initial parts of the intestine appear earlier than others.

According to the clinical course, all patients with tumors of the small intestine can be divided into two groups: 1) with an uncomplicated course and 2) with the development of complications. Uncomplicated forms include asymptomatic ones, simulating tumors of other organs and tumors accompanied by symptoms of enteritis.

Local clinical symptoms are associated primarily with the appearance of abdominal pain, especially characteristic of malignant tumors. With neoplasms of the upper intestine, pain is localized in the epigastric region.

At first, they are intermittent, insignificant in intensity, and are accompanied by belching and nausea. If the tumor is localized in the middle and distal parts, the pain moves to the navel area, the right iliac region. Abdominal bloating is often noted, and splashing noise is occasionally noted.

A picture of partial intermittent intestinal obstruction may occur. In these cases, the pain may intensify, become cramping, and be accompanied by nausea and vomiting. The stomach becomes bloated. On palpation, a splashing noise is clearly detected.

Auscultation can detect increased peristaltic sounds. The first attacks of intermittent partial intestinal obstruction may go away on their own. With repeated attacks, partial obstruction can become complete.

An important local sign (in 30% of patients) can be a palpable tumor in the abdomen. As a rule, it is defined as a dense, slightly painful or painless formation, often with limited mobility. With a tumor of the jejunum, it is palpated in the umbilical region or the left half of the abdomen.

An ileal tumor is palpated in the lower abdomen, in the right iliac region. Tumors of the distal small intestine and proximal ileum can descend into the pelvis and simulate pelvic organ tumors. They can sometimes be determined by vaginal and rectal examination.

Signs of impairment of the general condition of patients are characteristic of malignant tumors of the small intestine and appear the earlier, the more proximally the tumor is located. General weakness, malaise, loss of ability to work, loss of appetite, and loss of body weight appear.

An objective examination shows signs of anemia: pallor, cyanosis. Anemia is associated with both the possibility of hidden bleeding and intoxication.

Complicated forms include tumors that cause obstruction (including due to intussusception), bleeding and perforation with the development of peritonitis. Moreover, the described complications are often the first clinical manifestations of small intestinal tumors.

Intestinal obstruction often develops suddenly against the background of complete well-being. If it resolves on its own, then after a while a relapse occurs, i.e. there is a picture of intermittent intestinal obstruction.

Intestinal obstruction can be caused by a benign tumor of a large size, causing obstruction of the intestinal lumen, as well as intussusception, which occurs with a tumor of even small size and is usually localized in the terminal ileum.

Malignant tumors, even small ones, can cause a narrowing of the lumen of the small intestine and are more often than benign tumors complicated by acute intestinal obstruction.

Tumors prone to decay and ulceration (leiomyomas, hemangiomas, neuromas and any malignant tumors) are characterized by the development of clinical signs of bleeding or perforation.

Bleeding at the same time, they can be profuse in nature, manifesting well-known classical signs with life-threatening hemodynamic disturbances and blood loss. In addition, in the early stages of the disease, hidden bleeding is observed, which over a long period of time leads to the development of severe anemia.

Perforation due to its disintegration, the tumor also develops suddenly, manifesting itself with characteristic signs of perforation of a hollow organ and subsequent peritonitis. It should be noted that clarifying the follow-up in patients with complicated forms allows us to identify a number of clinical signs.

This “hidden” or latent period can last quite a long time and is characterized by the appearance of causeless weakness, a feeling of heaviness in the abdomen, the presence of periodic and short-term spasmodic pain in the abdomen at the height of digestion, nausea, occasional vomiting, unstable stools, and flatulence.

A number of patients experienced slight bleeding in the stool, decreased appetite and weight loss, and unexplained low-grade fever. Thus, the concept of “asymptomatic” course is very conditional.

Peutz-Jagers syndrome has a unique clinical picture. The peculiarity is that in addition to the clinical signs characteristic of a tumor, patients have brown, black or bluish-gray spots on the legs, palms, around the eyes, nostrils, on the mucous membrane of the mouth and nose.

Peutz-Jagers syndrome can be combined with intestinal diverticula and ovarian tumors.

Instrumental diagnostics.

Analysis of peripheral blood in some patients reveals moderate leukocytosis and an increase in ESR. With developed perforation with peritonitis and acute intestinal obstruction, this indicator has a characteristic increase and a shift towards younger forms in the leukocyte formula.

Anemia is determined in patients with hidden bleeding. The latter can be revealed with appropriate scatological examination.

Until recently, the leading role in the diagnosis of tumors of the small intestine belonged to X-ray examination. To detect a tumor of the small intestine, various radiopaque techniques are used, based on filling the small intestine with a suspension of barium sulfate and monitoring the progress of the contrast mass.

X-ray signs of tumors are filling defects in the lesions. As a rule, especially with polyps, these defects have a rounded shape and clear contours. If the tumor has a stalk, then its free end is mobile and often deviates along the flow of the contrast suspension.

In the tumor zone, there may be a delay in the barium mass, dilatation of the small intestine proximal to the tumor. With bowel sarcomas, this phenomenon, called Rovenkamp, ​​is observed even in the absence of narrowing.

A gas bubble may be detected over the area of ​​stenosis. Narrowing in cancer of the small intestine may have a concentric or conical shape, less often a marginal filling defect with pitted edges is determined.

X-ray examination of the small intestine sometimes presents significant difficulties. At the same time, many authors report a high error rate during its implementation. Due to the fact that X-ray methods do not in all cases make it possible to establish the correct diagnosis and the diagnostic period is sometimes extended for 12 months, the search for more advanced and informative methods is justified.

These include double-balloon enteroscopy - an endoscopic examination of the small intestine. Meanwhile, the technical complexity of this technique, the need for deep sedation or even general anesthesia to perform it, and the high cost of diagnostic equipment have not ensured widespread use of the method.

Apparently, it is of little promise for the study of the ileum.

Since 2000, the video capsule endoscopy technique has been introduced into world practice. In July 2003, the US Drug Administration (FDA) designated capsule endoscopy as a primary tool in detecting small bowel pathology.

According to most research centers, endoscopic capsule technology is the most sensitive in diagnosing diseases of the small intestine. The essence of the technique is as follows.

The patient swallows a device (Fig. 2) measuring 23 x 11 mm (slightly larger than a drug capsule) containing a miniature color video camera, a radio transmitter, a light source and a battery that ensures the operation of the device for 8 hours. The video capsule moves along the digestive tract by means of peristalsis, while the video camera captures an image of the intestinal mucosa at a frequency of 2 frames per second.

The received information is transmitted wirelessly to sensors placed on the patient's body in a certain sequence and stored in a recording device that the patient wears on his belt. Subsequently, images of the patient's gastrointestinal tract are read by a personal computer for evaluation by the research physician.

The positive qualities of this technique are its non-invasiveness, painlessness, the possibility of an outpatient study. However, there are disadvantages and limitations of the applicability of this method.

Thus, the most significant drawback of the technique is the uncontrollability of the movements of the capsule and the inability to conduct a biopsy of the identified pathological formations. In addition, a contraindication to videocapsule endoscopy is the presence of signs of impaired patency of the gastrointestinal tract.

Rice. 2. Appearance of the device for capsule endoscopy

The diagnostic program for complications of tumors of the small intestine is dictated by their nature and, of course, has a very reduced volume.

Treatment.

For benign tumors less than 1 cm in size, excision of the tumor within healthy tissue is considered acceptable. This can be done if the tumor is located along the free edge of the intestine.

When the tumor is located on the lateral walls, it is advisable to perform a three-quarter resection. If the tumor is localized along the mesenteric edge, then only circular resection of the section of intestine with the tumor is possible.

If the tumor size exceeds 1 cm, resection of the small intestine is necessary. This general surgical routine operation is performed according to well-known classical principles.

Surgical treatment of malignant tumors of the small intestine should be based on strict adherence to oncological principles. Resection of the small intestine should be carried out at a distance of at least 10 cm from the edge of the tumor, along with removal of the corresponding segment of the mesentery with the lymph nodes located in it.

If metastases are located at the mouths of the superior and inferior mesenteric arteries (at the root of the mesentery), then radical surgery is impossible.

When the tumor is localized in the distal segments of the ileum (within an area of ​​20 cm from the ileocecal angle), the peculiarities of blood supply and metastasis require, together with intestinal resection, a right-sided hemicolectomy with the imposition of an ileotransverse anastomosis.

Operations performed for complications of malignant tumors of the small intestine are indistinguishable from planned operations in scope and nature. Unfortunately, radical operations are impossible in 50-60% of patients.

The most common indication for palliative interventions for cancer and sarcoma is obstructive intestinal obstruction in the presence of distant tumor metastases. In this case, it is advisable to apply bypass anastomoses.

For bleeding tumors with extensive metastases, hemostasis can be reliably achieved only with the help of palliative bowel resection. It should also be considered appropriate in the late stages of carcinoid, since specific therapy for metastases is possible.

Combination treatment has been undertaken by a number of authors for sarcomas of the small intestine. Radical surgery was supplemented with radiation or chemotherapy (cyclophosphamide, thiotef, ftorafur, etc.). The experience of such treatment is small and the results cannot be called satisfactory: postoperative mortality is high, and relapses are frequent.

To a greater extent, one should count on the success of combination treatment for carcinoids. As already mentioned, radical surgery for carcinoids is performed according to the same oncological principles as for cancer and sarcomas. It is a generally accepted point of view that even in the presence of a close or distant metastasis that cannot be removed, removal of the primary tumor is not contraindicated.

Unlike other malignant neoplasms, excision of a primary carcinoid tumor does not accelerate the growth of metastases. With multiple metastases of malignant tumors in the liver, chemoembolization of the hepatic vessels and program hepatoperfusion using chemotherapeutic drugs can be used.

Evidence of the effectiveness of chemotherapy for malignant tumors is a significant increase in life expectancy. However, the use of this criterion in carcinoids is difficult due to the large variability in the course of the disease and the lack of use of chemotherapy.

The results of surgical treatment of benign tumors are quite satisfactory, postoperative mortality does not exceed 2-3%.

After various operations in patients with malignant tumors of the small intestine, the immediate results can also be considered satisfactory. Postoperative mortality is 2-5%.

The average numbers of postoperative mortality with the inclusion of advanced stages of the disease and complicated forms in the statistics increase to 13%. The duration of survival in patients with malignant tumors of the small intestine is on average 30.5 months, of the ileum - 33.5 months.

The best long-term results of surgical treatment are observed in patients with leiomyosarcoma: 5-year survival is observed in 40% of patients. In patients with adenocarcinoma this figure is 36%, in patients with lymphosarcoma - 20%, carcinoids - 50.5%.

ON THE. Yaitsky, A.V. Sednev

– neoplasms of various histological structures affecting any part of the small intestine. Symptoms of the disease depend on the location of the tumor and may include abdominal pain, intoxication, anemia, cachexia, alternating constipation and diarrhea, bleeding, and intestinal obstruction. To establish the nature and localization of the tumor lesion, endoscopic examination with biopsy, ultrasound of the abdominal organs, X-ray techniques, and diagnostic laparoscopy are used. Treatment of tumors of the small intestine is surgical, supplemented with chemotherapy if necessary.

General information

Tumors of the small intestine are a group of benign or malignant neoplasms affecting the duodenum, ileum and jejunum. A tumor localized in the small intestine is extremely rarely diagnosed intravitally, as it does not have obvious symptoms and is successfully disguised as other diseases. Despite the fact that the small intestine represents 3/4 of the entire length of the digestive tract and more than 90% of its area, tumors of this part of the gastrointestinal tract occur only in 0.5-3.5% of cases. Malignant tumors of the small intestine are diagnosed even less often and account for 0.01% of all oncopathology of the small intestine.

The rare occurrence of malignant neoplasms of the small intestine is associated with the peculiarities of its structure and functioning: active peristalsis and an alkaline environment prevent stagnation of the contents and the proliferation of bacteria, and the intestinal wall secretes various protective and antitumor agents that inactivate carcinogenic substances. Tumors of the small intestine are almost never diagnosed in children, and in adults, the peak detection rate occurs at the age of 40-50 years, regardless of gender. Benign neoplasms most often affect the duodenum and ileum, and malignant neoplasms most often affect the distal ileum and initial parts of the jejunum. Among benign tumors in the small intestine, polyps are more common, and among malignant tumors, cancer is more common.

Causes

The exact reasons for the degeneration of normal intestinal cells into tumor cells are still unknown. Doctors identify a number of factors predisposing to this disease. These include familial adenomatous polyposis (in almost 100% of cases it leads to malignancy); genetic predisposition (episodes of detection of small intestinal tumors in close relatives); chronic inflammatory diseases of the digestive tract (Crohn's disease); Peutz-Jeghers syndrome; celiac disease; elderly age; nutritional disorders, especially the predominance of protein and fat in food, lack of fiber.

Familial polyposis leads to the formation of adenocarcinoma (most often in the duodenum) in one case per 1,700 patients. Patients with familial polyposis should undergo annual endoscopic examination, and if polyps and other pathology are detected, they undergo a biopsy. Hereditary Peutz-Jeghers disease is skin hyperpigmentation associated with polyps of the stomach and intestines. A malignant tumor of the small intestine (adenocarcinoma) develops in one of these polyps in 2.5% of cases. It should be borne in mind that small intestinal polyps are quite difficult to diagnose, so dynamic monitoring of such patients is difficult. Polyposis of the gastrointestinal tract predisposes to malignant neoplasms not only of the intestines, but also of other organs.

Crohn's disease increases the risk of small intestinal tumors by more than a hundredfold, and malignancy usually occurs at a young age. All patients with this pathology who have interintestinal fistulas and strictures that are difficult to treat are recommended to undergo resection of the affected areas to prevent the formation of adenocarcinoma of the small intestine.

A tumor of the small intestine, such as lymphoma, often develops in patients with immunodeficiency or immunosuppression (AIDS, treatment after organ transplantation, chemotherapy, exposure to ionizing radiation), as well as in the presence of systemic diseases, celiac disease, etc.

Classification

The neoplasm can grow both into the intestinal lumen (exophytic growth) and infiltrate the intestinal wall (endophytic growth). Endophytic tumors of the small intestine have a more unfavorable prognosis, since they do not manifest themselves for a long time. Over time, the growth of the tumor becomes mixed - the intestinal wall is affected over a large area, and the tumor itself blocks the lumen of the digestive tube.

According to the histological structure, tumors of the small intestine are very polymorphic: epithelial and non-epithelial, carcinoids, lymphoid, secondary and tumor-like processes. Based on the nature of the process, neoplasms are divided into benign and malignant. Benign epithelial tumors include adenomas (villous, tubular, tubular-villous); to malignant - mucinous and simple adenocarcinoma, signet ring cell carcinoma, undifferentiated and unclassified forms of cancer. Benign non-epithelial tumors - leiomyoma, leiomyoblastoma, neurilemmoma, lipoma, hemangioma, lymphangioma. Leiomyosarcoma is a malignant tumor.

Carcinoids include argentaffin, non-argentaffin and mixed neoplasms. Lymphoid tumors are represented by lymphosarcoma, reticulosarcoma, lymphogranulomatosis and Burkitt's lymphoma. Tumor-like processes include hamartomas (juvenile polyposis, Peutz-Jeghers syndrome), heterotopias (from tissue of the stomach, pancreas, Brunner's glands, benign lymphoid polyps and hyperplasia, endometriosis).

Symptoms of small intestinal tumors

The insidiousness of neoplasms is that they do not manifest themselves for a long time, or the clinical picture is dominated by symptoms characteristic of other diseases (peptic ulcer of the stomach and duodenum, cholecystitis, adnexitis, etc.). In 75% of patients, tumors of the small intestine are discovered only after death; in other cases, the tumor is usually diagnosed at an advanced stage, when the intestinal lumen is blocked and a clinical picture of intestinal obstruction occurs.

The first manifestation of benign tumors of the small intestine may be pain. Patients describe the pain as vague, localized in the navel or to the left of it, in the iliac region. Pain usually occurs when a neoplasm grows into the intestinal wall and spreads to the peritoneum and other organs. In addition, the patient may be bothered by belching, flatulence, stool instability, loss of appetite, emaciation, and a moderate increase in body temperature.

There are no symptoms that can be used to determine the type of tumor, however, for some benign neoplasms, certain clinical manifestations are more typical. For example, for polyps of the small intestine, the development of a clinical picture of intestinal obstruction (due to intussusception) is typical against the background of general well-being. If left untreated, intestinal obstruction recurs many times in the future. Leiomyomas can reach enormous sizes, blocking the intestinal lumen and squeezing surrounding organs. Often the surface of the leiomyoma ulcerates, leading to chronic intestinal bleeding and anemia. Hemangiomas of the small intestine are the rarest benign tumor of the gastrointestinal tract (0.3% of all neoplasms of the digestive tract). Even small cavernous hemangiomas often lead to bleeding, and large formations lead to intestinal obstruction.

In the clinical picture of benign tumors of the small intestine, three periods are distinguished: latent (no symptoms), prodromal (vague and nonspecific complaints appear), period of pronounced clinical manifestations (various complications arise - intestinal obstruction, intestinal perforation, bleeding).

Malignant tumors can have both general manifestations (exhaustion, intoxication, pallor of the skin and mucous membranes) and local symptoms, which depend on the location and size of the tumor. The most significant manifestation of a malignant neoplasm is usually pain; over time, the pain gradually increases and becomes unbearable. In addition, the patient complains of nausea, vomiting, and debilitating heartburn. In the initial stages of a malignant tumor, diarrhea alternates with constipation; in the terminal period, a clinical picture of intestinal obstruction and perforation of a hollow organ (associated with the disintegration of the tumor) develops.

All intestinal neoplasms are accompanied by cachexia, anemia, and intoxication. Anemia is associated not only with constant bleeding, but also with impaired absorption of nutrients in the affected intestine, necessary for normal hematopoiesis. Typically, a pronounced clinical picture indicates not only an advanced stage of the disease, but also metastasis of the tumor to the lymph nodes and other organs.

Diagnostics

Patients with the symptoms described above most often turn to a gastroenterologist for the first time, and the timely detection of a tumor of the small intestine depends on this specialist. The first place a diagnostic search begins is an x-ray examination. On a plain radiography of the abdominal organs, the tumor is visualized as a defect in the filling of the intestinal tube. To clarify the location and size of the tumor, radiography of the passage of barium through the small intestine may be required. To improve the quality of the study, simultaneous injection of gas into the abdominal cavity (double contrast) is sometimes used - this makes it possible to better visualize the tumor conglomerate, identify even small tumors and clearly determine their location.

If the small intestine is damaged, it is preferable to consult an endoscopist, who will decide on further tactics for examining the patient. Intestinoscopy will not only allow visualization of the tumor during its exophytic growth, but will also make it possible to conduct endoscopic biopsy and collect material for accurate preoperative diagnosis. If a tumor is suspected in the initial parts of the small intestine, an endoscopic examination is carried out using a modified fiber gastroscope, and if the distal parts (ileum) are affected, with a fiber colonoscope.

If difficulties arise, diagnostic laparoscopy can help establish the correct diagnosis. During this study, internal organs and regional lymph nodes are examined, a tumor of the small intestine is identified, the extent of its spread to surrounding organs and vessels is assessed, and a biopsy of the tumor is performed.

In the presence of a tumor of the small intestine, ultrasound of the abdominal organs, retroperitoneal space, and supraclavicular areas is mandatory. Magnetic resonance and computed tomography of the abdominal organs and mediastinum, and, if possible, single-photon emission computed tomography of internal organs will help complete the picture of the disease. A complete blood count and stool test for occult blood will help identify even minor bleeding.

Treatment of small intestinal tumors

At the initial stage, the patient may be in the gastroenterology department. Once the diagnosis is confirmed, further treatment tactics are developed in the department of surgery or oncology. Treatment of benign tumors of the small intestine is only surgical. Removal of small intestinal polyps can be done during an endoscopic examination. Larger benign tumors are removed by wedge resection or segmental resection of the intestine.

For certain types of malignant neoplasms, chemotherapy can be performed to reduce the size of the tumor before surgery (or to alleviate the condition of a patient with an incurable tumor). Chemotherapy can also be used after surgery to improve the prognosis and prevent metastasis. At the initial stages of the disease, a resection of part of the small intestine with the mesentery and regional lymph nodes is performed; if the process spreads to surrounding organs, a palliative operation is performed (bypass). In developed countries, laparoscopic techniques for removing tumors of the small intestine are being actively introduced.

Prognosis and prevention

The prognosis for the presence of a small intestinal tumor depends on many factors. Timely diagnosed and removed benign tumors of the small intestine have a favorable prognosis. The main criterion for prognosis in malignant neoplasms is the prevalence of the process according to the TNM classification. The prognosis worsens significantly when metastases are detected, tumor growth into surrounding tissues, fatty tissue, and blood vessels. There is also a clear relationship between a high level of carcinoembryonic antigen and tumor recurrence - even small tumors without metastases almost always recur if this indicator is significantly elevated. It has been proven that if the tumor has not recurred within five years after treatment, then the tumor process will not return.

Prevention of tumors of the small intestine includes a set of measures to improve and improve lifestyle (cessation of smoking, alcohol, proper nutrition with enough fiber, maintaining good physical shape and normal weight), as well as regular examinations of all people at risk after 50 years and timely removal of benign intestinal tumors.

Malignant neoplastic lesions of the small intestine: duodenum, jejunum or ileum. Cancer of the small intestine manifests itself as dyspeptic disorders (nausea, vomiting, flatulence, spastic abdominal pain), weight loss, bleeding, intestinal obstruction. Diagnosis of cancer of the small intestine can be carried out using EGD, radiography, capsule endoscopy, colonoscopy, gastrointestinal scintigraphy, tomography, endoscopic biopsy, laparoscopy. Treatment of small intestine cancer consists in resection of the affected area of ​​the intestine, excision of regional lymph nodes and mesentery, and the imposition of enteroenteroanastomosis.

General information

In the structure of malignant tumors of the digestive tract, small intestine cancer is 1-2%. Among neoplasms of the small intestine in gastroenterology, duodenal cancer is more common (about 50% of cases); less often - jejunal cancer (30%) and ileal cancer (20%). Small intestinal cancer is a disease that predominantly affects men over the age of 60.

Causes of small intestine cancer

In most cases, small intestinal cancer develops against the background of chronic enzymatic or inflammatory diseases of the gastrointestinal tract (celiac disease, duodenitis, peptic ulcer, enteritis, Crohn's disease, ulcerative colitis, diverticulitis) or benign epithelial intestinal tumors. The predominant damage to the duodenum is explained by the irritating effect of bile and pancreatic juice on the initial part of the small intestine, as well as its active contact with carcinogens entering the digestive tract with food.

Cases of sporadic or familial adenomatous polyposis are increased risk factors for developing small intestinal cancer. The likelihood of small intestinal cancer is higher in smokers, people exposed to radiation, and those with alcohol addiction; people whose diet is dominated by animal fats, canned foods, and fried foods.

There is a certain mutual relationship between colon cancer and tumor damage to the small intestine.

Classification of small intestine cancer

Based on the nature of the growth of tumor tissue, exophytic and endophytic cancer of the small intestine are distinguished. Exophytic tumors grow into the intestinal lumen, causing its narrowing and the development of intestinal obstruction; macroscopically may resemble a polyp or cauliflower. Endophytic forms of cancer infiltrate the wall of the small intestine in depth, accompanied by intestinal bleeding, perforation and peritonitis.

According to the histological structure, malignant tumors of the small intestine are often represented by adenocarcinoma; Less common in oncological practice are sarcomas, carcinoids, and intestinal lymphoma.

According to the clinical and anatomical classification according to the international TNM system, the development of small intestine cancer is divided into stages:

• Tis - preinvasive cancer
• T1 – tumor invasion of the submucosal layer of the intestine
• T2 – tumor invasion of the muscular layer of the intestine
• T3 – tumor invasion of the subserous layer of the intestine or retroperitoneal space in an area of ​​no more than 2 cm
• T4 – tumor invasion of the visceral peritoneum, non-peritoneal areas more than 2 cm in length, structures or organs adjacent to the intestine.
• N0 and M0 – absence of regional and isolated metastasis
• N1 – metastatic lesion of regional lymph nodes (pancreaticoduodenal, pyloric, hepatic, mesenteric).
• Ml – the presence of distant metastases in the peritoneum, liver, omentum, lungs, kidneys, bones, adrenal glands.

Symptoms of small intestine cancer

Manifestations of small intestinal cancer are characterized by polymorphism, which is associated with variability in the location, histology and size of the tumor. In the initial stages, periodic spasmodic pain in the abdomen, stool instability (diarrhea and constipation), flatulence, nausea and vomiting are disturbing. Intoxication and progressive loss of body weight are noted, which is associated both with decreased nutrition and tumor growth.

Destructive processes in small intestinal cancer can lead to the development of intestinal bleeding, perforation of the intestinal wall, entry of contents into the abdominal cavity and peritonitis. Exophytic growth of tumors is often accompanied by obstructive intestinal obstruction with a corresponding clinical picture. When the tumor compresses neighboring organs, pancreatitis, jaundice, ascites, and intestinal ischemia may develop.

Sometimes there is fusion of the tumor with neighboring intestinal loops, the bladder, large intestine, and omentum with the formation of a single, sedentary conglomerate. When small intestinal cancer ulcerates and disintegrates, intestinal fistulas can occur.

Diagnosis of small intestine cancer

The diagnostic algorithm for small intestinal cancer of various locations has its own characteristics. Thus, in the recognition of tumors of the duodenum, fibrogastroduodenoscopy and contrast fluoroscopy play a leading role. Colonoscopy and irrigoscopy can be informative for diagnosing tumors of the terminal ileum.

An important role in the diagnosis of small intestinal cancer is played by barium passage radiography, which makes it possible to identify obstacles to the advancement of the contrast agent, areas of stenosis and suprastenotic dilatation of the intestine. The value of endoscopic studies lies in the possibility of performing a biopsy for subsequent morphological verification of the diagnosis. Selective angiography of the abdominal cavity may be of certain diagnostic interest.

In order to detect metastases and germination of small intestinal cancer into the abdominal organs, ultrasound (liver, pancreas, kidneys, adrenal glands), MSCT of the abdominal cavity, chest radiography, bone scintigraphy are performed. In unclear cases, diagnostic laparoscopy is advisable.

Small intestinal cancer must be differentiated from intestinal tuberculosis,

For duodenal cancer, duodenectomy is indicated, sometimes with distal gastrectomy or pancreatic resection (pancreaticoduodenectomy). For advanced small intestinal cancer that does not allow radical resection, a bypass anastomosis is performed between unaffected loops of intestine. The surgical stage of treatment of small intestinal cancer is supplemented by chemotherapy; this same method may be the only way to treat inoperable tumors.

Prognosis and prevention of small intestinal cancer

The long-term prognosis for small intestinal cancer is determined by the stage of the process and the histological structure of the tumor. For localized tumor processes without regional and distant metastases, radical resection allows to achieve 35-40% survival over the subsequent 5-year period.

Prevention of small intestinal cancer requires timely removal of benign intestinal tumors, observation by a gastroenterologist of patients with chronic inflammatory processes of the gastrointestinal tract, smoking cessation, and normalization of nutrition.