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General Surgery
Tumors of the Small Intestine
Built from Maingot's Abdominal Operations
What’s inside
14 sections · 109 slides
Overview
- Scope of this topic
- Tumour types arising in the small intestine
Epidemiology
How rare these tumours are, and who gets them
- 75%
- Rarity of small bowel tumours
- Limits of the published evidence
- Age, sex and geographic pattern
Pathogenesis
Why cancer so rarely starts in the small bowel
- Absence of a defined progression sequence
- Protective features of the small bowel lumen
- Luminal protective mechanisms
- Cellular and immune protective mechanisms
- Bile acids and prior cholecystectomy
High-risk conditions
Inherited and inflammatory diseases that raise the risk
- Familial adenomatous polyposis
- Crohn's disease
- Celiac disease
- Peutz-Jeghers syndrome and von Recklinghausen's disease
- Chronic immunosuppression and post-transplant lymphoproliferative disorder
- HIV-associated gastrointestinal lymphoma
- Conditions that raise small bowel tumour risk
Clinical presentation
Vague symptoms and a long delay to diagnosis
- Presenting symptoms
- Causes of diagnostic delay
- Presentation of benign lesions
Diagnosis
Imaging, contrast studies, capsule and endoscopy
- Obstacles to diagnosis
- Initial tests
- Computed tomography findings
- Ileal adenocarcinoma on abdominal CT
- Intussusception as a presenting sign
- Ileocolic intussusception on CT
- Mechanism of tumour-led intussusception
- Management of adult intussusception
- Contrast radiography and enteroclysis
- Enteroscopy techniques
- Video capsule endoscopy
- Small bowel adenocarcinoma seen through the video capsule
- Limitations of video capsule endoscopy
- Nuclear medicine imaging and stage at presentation
Benign tumors
Adenomas, lipomas, hamartomas and hemangiomas
- Frequency and presentation of benign tumors
- Principles of resection for benign lesions
- Brunner gland adenoma
- Adenomas of the small bowel
- Detection of duodenal adenomas
- Duodenal filling defect from a benign adenoma
- Assessment and excision of duodenal adenomas
- Outcome after local excision of ampullary adenomas
- Lipomas
- Hamartomas in Peutz-Jeghers syndrome
- Hemangiomas
Malignant neoplasms
The four common cancers and how they behave as a group
- Range of malignant tumors
- Stage at presentation and second primary tumors
Adenocarcinoma
The commonest primary cancer of the small bowel
- Distribution and risk factors for adenocarcinoma
- Clinical presentation of adenocarcinoma
- Apple-core constricting adenocarcinoma of the proximal jejunum
- Diagnosis of adenocarcinoma
- Surgical management of adenocarcinoma
- Palliative options in advanced adenocarcinoma
- Staging of small bowel adenocarcinoma
- Prognostic factors and adjuvant therapy
Non-Hodgkin's lymphoma
The gut is the commonest site outside lymph nodes
- Distribution of gastrointestinal lymphoma
- Diagnostic criteria for primary gastrointestinal lymphoma
- Cell types and MALT lymphoma
- Presentation and diagnosis of small bowel lymphoma
- Bowel wall thickening of small bowel lymphoma on CT
- Tissue diagnosis and stage at presentation
- Stage groups used for gastrointestinal lymphoma
- Stage I and stage II disease
- Stage III and stage IV disease
- Treatment of gastrointestinal lymphoma
Carcinoid tumors
Hormone-producing tumors, desmoplasia and carcinoid syndrome
- Cell of origin and hormone production
- Anatomical distribution of carcinoid tumors
- Epidemiology of small bowel carcinoid
- Clinical presentation of carcinoid tumors
- Multiple tumors and desmoplastic reaction
- Tumor size and risk of metastatic spread
- Prognosis and extent of resection
- Carcinoid syndrome
- Why carcinoid syndrome requires metastatic disease
- Hepatic clearance and sites that bypass it
- Flushing, diarrhea and precipitating factors
- Carcinoid heart disease
- Surgical management of metastatic carcinoid
- Interventional and medical therapy for carcinoid syndrome
- Chemotherapy and targeted radiotherapy for carcinoid
- Radiolabeled somatostatin analogues
Gastrointestinal stromal tumors
From the pacemaker cell of the gut to targeted therapy
- Frequency and distribution of GIST
- Cell of origin and the kit mutation
- Molecular reclassification of mesenchymal tumors
- Clinical behaviour and growth pattern of GIST
- Computed tomography appearance of GIST
- Large gastric GIST invading the diaphragm and spleen on CT
- Assessment of malignant potential in GIST
- Determinants of GIST risk grade
- Surgical treatment of GIST
- Kit signalling and the action of imatinib
- Molecular basis of targeted therapy in GIST
- Clinical use of imatinib
- Resistance and second-line therapy
- Imatinib before and after surgery
Metastases to the small bowel
More common than primary tumors, and mostly palliative
- Routes of metastatic spread to the small bowel
- Imaging of small bowel metastases
- Palliative management of metastatic disease
- Palliative options by site of obstruction
Summary
What to carry away
- Key points on presentation and diagnosis
- Key points on tumour types
- Key points on treatment
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition