noisoi08
90
NOÄI SOI MEDIC TRUNG TAÂM Y KHOA MEDIC CME MEDIC 254 Hoøa Haûo Q. 10 TP. Hoà Chí Minh ÑT: 8357284 8355 136 fax: 8488352543 email: medic@hcm. vnn. vn EXIT SIEÂU AÂM CT SCAN NOÄI SOI PHOØNG KHAÙM XEÙT NGHIEÄM DSA X QUANG MRI DUODENAL TUMORS NGUYEÃN SÔN TAÂY
description
U ta trang
Transcript of noisoi08
DUODENAL TUMORSCME
MEDIC 254 Hoøa Haûo Q. 10 TP. Hoà Chí Minh ÑT: 8357284 8355 136 fax: 8488352543 email: medic@hcm. vnn. vn
EXIT
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
A. INCIDENCE:
10%20% of small bowel tumors. ( #0, 6% all gastrointestinal benign and malignant neoplasms)
Equal in both men and women.
Approximately 2500 cases of small bowel tumors occur annually in the US
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
The most common duodenal tumor
They appear as both sessile and pedunculated polyps. The surface is the same collor of the surrounding mucosa.
Histological classify :
+Tubular
+Tubulovillous : if more than 2025% but less than 7580% of the polyp consists of vilous elements
+Vilous: high degree of malignant potential
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
2. Leiomyoma
The most frequently occurring benign tumor in the small intestine. Most common in the jejunum. 1020% in the duodenum.
Round or ovoid sessile polyp, rarely pedunculate, with a smoothly tapering border. The central hemorrhagic ulcer should arouse a suspicion of leiomyoma.
Most leiomyomas arise from the muscularis propria. Leiomyomas are composed of bundles of spindleshaped smooth muscle cells with elongated nuclei and abundant cytoplasm arranged in a herringbone pattern. Differentiation from leiomyosarcomas is difficult. Absence of cellular pleomorphism, rare mitotic activity, and no invasion of surrounding tissue are indications of benign status.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
3. Lipoma
They appear in the colon( 6570%), the ileum, the duodenum, and the jejunum.
stroma.
They arise from the submucosal adipose tissue or serosal fat and thus are typically extramucosal in location.
Histologically, they are composed of mature adipose tissue supported by a fibrous
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
They make up 3050% of benign lesions of the duodenum.
they are usually smaller than 1cm and often multiple and polypoid.
Microscopically, they are composed of enlarged aggregates of glandular tissue often in the form of a polypoid mass. Intersection of the glandular structure by bands of smooth muscle, cystic dilatation of the glandular structure, and a fibrous capsule are characteristic
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
They may be solitary or multifocal and may arise from nerve sheaths (neurilemomas), sympathetic ganglia (ganglioneuromas), and neural connective tissue (neurofibromas).
They may be associated with cafe au lait spots and cutaneous neurofibromas (von Recklinghausen ‘s disease).
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
6. Angiomas
They can be subdivided into hemangiomas or true vascular tumors (5% of all small bowel tumors) and telangiectasias or focal angio dysplasia.
Histologically, hemangioma are bloodfilled sinuses with endothelial lining.
Telangiectasia may be hereditary or acquired.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Three subgroups have been described:
+Type I: Commonly found in the right segment of the colon of elderly people
+Type II: Congenital ( autosomal recessive)and presents as gross varices in the small intestine of people younger than 20 years of age.
+Type III: OslerWeberRendu syndrome, is familial, occurs in an autosomal dominant pattern, and involves the entire gut.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Mode of transmission:
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
0, 35% of all gastrointestinal carcinomas.
The lesion are usually polypoid but can infiltrate the duodenal wall to produce annular constriction. 2/3 of duodenal adenocarcinoma are in the region of the ampulla of vater.
Regional lymph nodes and the liver are the most common metastatic sites.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
2. Carcinoids:
The second most common small bowel malignancy. Most frequently in the ileum. When arising in the duodenum, they tend to be less aggressive in terms of inducing desmoplasia and metastasis.
Typically, carcinoids appear as small submucosal nodules, but they can become polypoid.
Microscopically, they are composed of uniform, small, round cells that assume a variety of histologic patterns
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
3. Sarcoma
The third most common malignancy of the small bowel, of which the leiomyosarcoma is the most frequent ( most common in the jejunum, 10% in the duodenum).
These tumors tend to grow slowly and may becom quite bulky. They often outgrow their bloodsupply and thus are subject to ulceration and necrosis.
Metastasis is usually directly to the peritoneum, less often by hematogenous spread to the liver, and least often by lymphogenous extension to regional nodes.
Sarcomas can arise from smooth muscle, connective tissue, fatty tissue, vascular components, or neural elements.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
4. Lymphoma:
Although rare in the gastrointestinal tract of adults, lymphoma is the most common digestive tract tumor in children.
Lymphomas may involve the bowel as primary growths or as expressions of a generalized lymphomatous process. Lymphomas can appear as fungating ulcerated masses or as diffuse thickening of the gut wall.
All forms of nonHodgkin ‘s lymphomas have been reported. Most are of the Bcell type
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
III. Metastases and contigious spreadings
The most common sources are breast carcinoma, lung carcinoma, and melanoma.
Cancers involving the duodenum by contiguous spread are
from pancreas, stomach, biliary tree, right kidney and the hepatic flexure of the colon.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
1. Bleeding:
Bleeding may be occult to massive and commonly results from ulceration and necrosis of the tumors.
Leiomyomas, leiomyosarcomas, and hemangiomas bleed more frequently than do other small bowel tumors.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
C. CLINICAL FEATURES
2. Bowel obstruction
Tumors obstructing the duodenal lumen produce symptoms of abdominal pain and often anorexia, nausea, and vomiting.
Bowel obstrustion can be caused by intussusception, with the tumors acting as the lead point, by annular constriction of the bowel, by volvulus, or by compression from an adjacent tumor mass.
3. Obstructive jaundice
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Unrevealing
A palpable mass often indicates a malignant growth, such as a lymphoma or a leiomyosarcoma, although benign leiomyomas may occasionally present as a mass.
Abdominal distention resulting from bowel obstruction is a late finding, as are hepatomegaly and extensive lymphadenopathy.
Melanin spots on the lips and buccal mucosa suggest the PeutzJeghers syndrome.
Angiomas visible under the nails and beneath the tongue suggest the OslerWeberRendu syndrome
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
1. Bariumcontrast radiography:.
Barium can be administered by mouth or through a tube passed through the stomach and into the duodenum (enteroclysis).
Localized filling defects in the opacified intestinal lumen have been produced by either intraluminal or extraluminal lesions.
Villous tumors: Dappled radiolucency of frondlike projections set in a matrix of barium (‘’soap bubble’’).
Smoothwalled polypoid defects suggest : Adenoma, Brunner ‘s gland adenoma, lipoma, leiomyoma (particularly if a central ulcer fleck is present), or carcinoid.
Luminal stenosis may indicate infiltration of the duodenal wall by tumor.
At least 15%30% false negative results.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
In most instances routine upper gastrointestinal endoscopy probably does not include bowel beyond the second portion of the duodenum.
Oral insertion of a smallcaliber colonoscope allows evaluation of the small bowel, at least to the proximal jejunum.
Endoscopy provides for photographic documentation and biopsy.
Endosonography permit precise delineation of intramural and extraluminal tumors, as well as of adjacent structures.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
aids in detection of hepatic metastasis, adenopathy, bowel wall thickening, extraluminal masses, and biliary onstruction.
Angiography may help define highly vascular tumors or sites of bleeding
Exploratory laparotomy, on occasion, may be the only method capable of establishing a diagnosis. This is more commonly the case in the presence of tumors distal to the duodenum.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
E. TREATMENT
The treatment of benign and malignant tumors of the duodenum is surgical removal.
1. Benign Polypoid Tumors:
Can often be accomplished by endoscopic snare and cautery. When involvement of the duodenum is extensive or when the configuration of the lesion precludes endoscopic removal, duodenotomy or duodenectomy may be necessary.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
(Whipple’s operation) is the usual procedure.
Malignant lesion of the duodenal bulb and of the third and fourth portions of the duodenum can often be ttacked successfully without pancreatectomy.
Except when used for the treatment of lymphomas, radiation and chemotherapy have not been notably successful
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Adenomas, especially familial polyposis, require careful follow up.
2. Malignant tumors:
Survival depends in large part on early diagnosis. Unfortunately 3050%of small bowel malignancy have metastasized by the time of discovery. Endoscopic examination offers the hope of earlier detection, particularly in the duodenum. Newer supplemental techniques such as needle biopsy and endoscopic ultrasonography may further improve diagnostic accuracy
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
10%-20% of small bowel tumors
Approximately 2500 cases of small bowel tumors occur annually in the us
Equal in both men and women
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
At least 15%-30% false negative results
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Duodenum
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Oral insertion of a small caliber colonoscope
Photographic documentation and biopsy
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Smoothly tapering border
Central hemorrhagic ulcer
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Angiography
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Malignant tumors:Whipple’s operation
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
30%-50% metastasized by the time of discovery
Endoscopic offers the hope of earlier detection
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
MEDIC 254 Hoøa Haûo Q. 10 TP. Hoà Chí Minh ÑT: 8357284 8355 136 fax: 8488352543 email: medic@hcm. vnn. vn
EXIT
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
A. INCIDENCE:
10%20% of small bowel tumors. ( #0, 6% all gastrointestinal benign and malignant neoplasms)
Equal in both men and women.
Approximately 2500 cases of small bowel tumors occur annually in the US
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
The most common duodenal tumor
They appear as both sessile and pedunculated polyps. The surface is the same collor of the surrounding mucosa.
Histological classify :
+Tubular
+Tubulovillous : if more than 2025% but less than 7580% of the polyp consists of vilous elements
+Vilous: high degree of malignant potential
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
2. Leiomyoma
The most frequently occurring benign tumor in the small intestine. Most common in the jejunum. 1020% in the duodenum.
Round or ovoid sessile polyp, rarely pedunculate, with a smoothly tapering border. The central hemorrhagic ulcer should arouse a suspicion of leiomyoma.
Most leiomyomas arise from the muscularis propria. Leiomyomas are composed of bundles of spindleshaped smooth muscle cells with elongated nuclei and abundant cytoplasm arranged in a herringbone pattern. Differentiation from leiomyosarcomas is difficult. Absence of cellular pleomorphism, rare mitotic activity, and no invasion of surrounding tissue are indications of benign status.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
3. Lipoma
They appear in the colon( 6570%), the ileum, the duodenum, and the jejunum.
stroma.
They arise from the submucosal adipose tissue or serosal fat and thus are typically extramucosal in location.
Histologically, they are composed of mature adipose tissue supported by a fibrous
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
They make up 3050% of benign lesions of the duodenum.
they are usually smaller than 1cm and often multiple and polypoid.
Microscopically, they are composed of enlarged aggregates of glandular tissue often in the form of a polypoid mass. Intersection of the glandular structure by bands of smooth muscle, cystic dilatation of the glandular structure, and a fibrous capsule are characteristic
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
They may be solitary or multifocal and may arise from nerve sheaths (neurilemomas), sympathetic ganglia (ganglioneuromas), and neural connective tissue (neurofibromas).
They may be associated with cafe au lait spots and cutaneous neurofibromas (von Recklinghausen ‘s disease).
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
6. Angiomas
They can be subdivided into hemangiomas or true vascular tumors (5% of all small bowel tumors) and telangiectasias or focal angio dysplasia.
Histologically, hemangioma are bloodfilled sinuses with endothelial lining.
Telangiectasia may be hereditary or acquired.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Three subgroups have been described:
+Type I: Commonly found in the right segment of the colon of elderly people
+Type II: Congenital ( autosomal recessive)and presents as gross varices in the small intestine of people younger than 20 years of age.
+Type III: OslerWeberRendu syndrome, is familial, occurs in an autosomal dominant pattern, and involves the entire gut.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Mode of transmission:
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
0, 35% of all gastrointestinal carcinomas.
The lesion are usually polypoid but can infiltrate the duodenal wall to produce annular constriction. 2/3 of duodenal adenocarcinoma are in the region of the ampulla of vater.
Regional lymph nodes and the liver are the most common metastatic sites.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
2. Carcinoids:
The second most common small bowel malignancy. Most frequently in the ileum. When arising in the duodenum, they tend to be less aggressive in terms of inducing desmoplasia and metastasis.
Typically, carcinoids appear as small submucosal nodules, but they can become polypoid.
Microscopically, they are composed of uniform, small, round cells that assume a variety of histologic patterns
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
3. Sarcoma
The third most common malignancy of the small bowel, of which the leiomyosarcoma is the most frequent ( most common in the jejunum, 10% in the duodenum).
These tumors tend to grow slowly and may becom quite bulky. They often outgrow their bloodsupply and thus are subject to ulceration and necrosis.
Metastasis is usually directly to the peritoneum, less often by hematogenous spread to the liver, and least often by lymphogenous extension to regional nodes.
Sarcomas can arise from smooth muscle, connective tissue, fatty tissue, vascular components, or neural elements.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
4. Lymphoma:
Although rare in the gastrointestinal tract of adults, lymphoma is the most common digestive tract tumor in children.
Lymphomas may involve the bowel as primary growths or as expressions of a generalized lymphomatous process. Lymphomas can appear as fungating ulcerated masses or as diffuse thickening of the gut wall.
All forms of nonHodgkin ‘s lymphomas have been reported. Most are of the Bcell type
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
III. Metastases and contigious spreadings
The most common sources are breast carcinoma, lung carcinoma, and melanoma.
Cancers involving the duodenum by contiguous spread are
from pancreas, stomach, biliary tree, right kidney and the hepatic flexure of the colon.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
1. Bleeding:
Bleeding may be occult to massive and commonly results from ulceration and necrosis of the tumors.
Leiomyomas, leiomyosarcomas, and hemangiomas bleed more frequently than do other small bowel tumors.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
C. CLINICAL FEATURES
2. Bowel obstruction
Tumors obstructing the duodenal lumen produce symptoms of abdominal pain and often anorexia, nausea, and vomiting.
Bowel obstrustion can be caused by intussusception, with the tumors acting as the lead point, by annular constriction of the bowel, by volvulus, or by compression from an adjacent tumor mass.
3. Obstructive jaundice
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Unrevealing
A palpable mass often indicates a malignant growth, such as a lymphoma or a leiomyosarcoma, although benign leiomyomas may occasionally present as a mass.
Abdominal distention resulting from bowel obstruction is a late finding, as are hepatomegaly and extensive lymphadenopathy.
Melanin spots on the lips and buccal mucosa suggest the PeutzJeghers syndrome.
Angiomas visible under the nails and beneath the tongue suggest the OslerWeberRendu syndrome
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
1. Bariumcontrast radiography:.
Barium can be administered by mouth or through a tube passed through the stomach and into the duodenum (enteroclysis).
Localized filling defects in the opacified intestinal lumen have been produced by either intraluminal or extraluminal lesions.
Villous tumors: Dappled radiolucency of frondlike projections set in a matrix of barium (‘’soap bubble’’).
Smoothwalled polypoid defects suggest : Adenoma, Brunner ‘s gland adenoma, lipoma, leiomyoma (particularly if a central ulcer fleck is present), or carcinoid.
Luminal stenosis may indicate infiltration of the duodenal wall by tumor.
At least 15%30% false negative results.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
In most instances routine upper gastrointestinal endoscopy probably does not include bowel beyond the second portion of the duodenum.
Oral insertion of a smallcaliber colonoscope allows evaluation of the small bowel, at least to the proximal jejunum.
Endoscopy provides for photographic documentation and biopsy.
Endosonography permit precise delineation of intramural and extraluminal tumors, as well as of adjacent structures.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
aids in detection of hepatic metastasis, adenopathy, bowel wall thickening, extraluminal masses, and biliary onstruction.
Angiography may help define highly vascular tumors or sites of bleeding
Exploratory laparotomy, on occasion, may be the only method capable of establishing a diagnosis. This is more commonly the case in the presence of tumors distal to the duodenum.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
E. TREATMENT
The treatment of benign and malignant tumors of the duodenum is surgical removal.
1. Benign Polypoid Tumors:
Can often be accomplished by endoscopic snare and cautery. When involvement of the duodenum is extensive or when the configuration of the lesion precludes endoscopic removal, duodenotomy or duodenectomy may be necessary.
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
(Whipple’s operation) is the usual procedure.
Malignant lesion of the duodenal bulb and of the third and fourth portions of the duodenum can often be ttacked successfully without pancreatectomy.
Except when used for the treatment of lymphomas, radiation and chemotherapy have not been notably successful
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Adenomas, especially familial polyposis, require careful follow up.
2. Malignant tumors:
Survival depends in large part on early diagnosis. Unfortunately 3050%of small bowel malignancy have metastasized by the time of discovery. Endoscopic examination offers the hope of earlier detection, particularly in the duodenum. Newer supplemental techniques such as needle biopsy and endoscopic ultrasonography may further improve diagnostic accuracy
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
10%-20% of small bowel tumors
Approximately 2500 cases of small bowel tumors occur annually in the us
Equal in both men and women
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
At least 15%-30% false negative results
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Duodenum
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Oral insertion of a small caliber colonoscope
Photographic documentation and biopsy
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Smoothly tapering border
Central hemorrhagic ulcer
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Angiography
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
Malignant tumors:Whipple’s operation
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
30%-50% metastasized by the time of discovery
Endoscopic offers the hope of earlier detection
NOÄI SOI MEDIC
SIEÂU AÂM
CT SCAN
NOÄI SOI
PHOØNG KHAÙM
XEÙT NGHIEÄM
