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Small bowel tumours (Clinical presentation (Change in bowel habit …
Small bowel tumours
Clinical
presentation
Change in bowel habit
(diarrhoea)
Carcinoid synd: colic abdo pain,
flushing, diarrhoea, wheeze
GI bleeding
Abdo pain
Anorexia, weight loss
Malaise/fatigue
Abdominal mass
Obstruction/perforation
Risk factors
Alcohol
Low fibre diet
Smoking
Bowel disease
Crohns, Coeliac
Genetic predisposition syndromes
Adenocarcinoma: FAP, HNPCC, Peutz-Jehger's
Neuroendocrine: MEN
Pathophysiology
Gastrointestinal stromal tumour (GIST)
Rarest type (10%)
Connective tissue (sarcomas) e.g. smooth muscle, fibroblasts, lipocytes (previously called leiomyosarcoma, liposarcoma etc.)
Myenteric plexi tumours are a variant (gastrointestinal autonomic nerve tumours, GANT)
Primary bowel lymphoma
Third commonest (20%)
Often NHL e.g. BCL (MALT)
Immunosuppression risk factors e.g. immunodeficiency syndrome, autoimmune disease (RA, SLE), infection (HIV), immunosuppressive drugs steroids, chemotherapy)
Carcinoid
Second commonest (25%)
Neuroendocrine, arise from enterochromaffin cells
Usually distal small bowel, appendix or Meckel's diverticulum
Often benign; can metastasise to the liver (carcinoid syndrome)
Carcinoid syndrome occurs when tumour mets to the liver and secretes vasoactive amines e.g. 5HT, histamine, substance P
Adenocarcinoma
Commonest (40%)
Often K-RAS and APC mutations
Often distal duodenum or proximal jejunum
Associated with FAP, Peutz-Jegher's, Crohn's, Coeliac
Complications
Obstruction
Perforation
Bleeding
Adenocarcinomas, GISTs
Malabsorption
Diagnosis
Examination
Abdo exam
Weight loss, pallor, distension,
tenderness, palpable mass
PR exam
May have malaena, fresh blood
Investigations
Bedside
Obs - HR, BP, sats, RR temp
ECG (nil)
Bloods
FBC (anemia, inflamm), CRP,
U+Es, LFTs (deranged if mets)
Coeliac serology
Imaging
AXR - obstruction
Erect CXR - perforation
Abdo/chest CT - diagnosis and staging
Small bowel follow through, CT angiography, ileoscopy
History
DH
Current meds, allergies, anticoagulants
FH
IBD, Coeliac, FAP, cancer
PMH
GIT disease (IBD, Coeliac, FAP), cancer
SH
Smoking, alcohol, diet
PC/HPC
Abdo pain, distension, haematemesis, malaena, fresh PR bleed, N+V, diarrhoea/constipation, change in
bowel habit, fevers, weight loss, malaise/fatigue
Management
Initial ABCDE
Definitive
Medical
Chemotherapy
Indication: metastatic adeno, lymphoma
Hepatic ablation/embolisation
Indication: carcinoid mets and carcinoid syndrome
Immune therapy
Indication: imatinib for c-Kit +ve GISTs, rituximab for lymphoma
MOA: imatinib (anti CD-113), rituximab (anti-CD20)
Surgical
Surgical resection
Indication: curative or palliative for
adenocarcinoma, GIST, carcinoid
Definition
Malignant neoplasm arising in the
small bowel (duodenum to ileum)
Epidemiology
RARE (1-25 GI tumours)