Intestinal tumours
*Intestinal tumours
*Melanin spots on the lips of a patient afflicted with Peutz–Jeghers syndrome *
Malignant tumours. In order of frequency, these are: Non-Hodgkin's lymphoma. Adenocarcinoma, Carcinoid tumour of the small intestine which is less common than that of the appendix but tends to be more malignant.*
Small bowel adenocarcinoma.
*TUMOURS OF THE LARGE INTESTINE
Colorectal tumours :- Tumours of the colon and the rectum share common properties and are, therefore, commonly referred to as colo-rectal tumours. Benign tumours :- Benign colorectal tumours usually form polyps.*
Malignant tumours Primary• Carcinoma.• Carcinoid tumour.• Sarcomas.Secondary. These are the result of invasion from a nearby malignant tumour.Two of the above tumours deserve detailed consideration, these are familial polyposis coli (FPC), and carcinoma. *
Familial adenomatous polyposis
*Familial adenomatous polyposis
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Clinical features Polyps usually present between the ages of 10 and 15 years. The commonest symptoms are diarrhoea, bleeding, arid abdominal pain. Investigations Barium enema shows multiple rounded filling defects throughout the colon and the rectum . Sigmoidectomy or colonoscopy and biopsy prove the nature of the disease.
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Carcinoma of the colon
*Carcinoma of the colon
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PathologyMicroscopically, the neoplasm is a columnar cell carcinoma originating in the colonic epithelium. Macroscopically, the tumor may take one of four forms .Type 4 is the least malignant form. It is likely that all carcinomas start as a benign adenoma, the so called ‘adenoma–carcinoma sequence’. The distribution of adenoma in the colon also mirrors that of carcinoma. The annular variety tends to give rise to obstructive symptoms, whereas the others will presentmore commonly with bleeding. The sites and distribution of cases of cancer are shown in the following FigureTumors are more common in the left colon and rectum. *
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The four common macroscopic varieties of carcinoma of the colon. (1) Annular; (2) tubular; (3) ulcer; (4) cauliflower.
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Staging Prognosis worsens with the progress of the stage. According to Duke's staging the tumour may be; Stage A The growth is limited to the bowel wall. Stage B The growth extends outside the bowel wall, bu no metastasis to lymph nodes. Stage C There are secondary deposits in the regiona lymph nodes. C1 The local para-rectal, or para-colic, lymph nodes alone are involved. C2 The nodes accompanying the supplying blood vessels are affected. This staging does not take in account the possibility of distant metastases. In a modified Duke's staging, it is termed "D stage".
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Clinical features
cancer of the rectum is commoner in males, while cancer of the caecum is commoner in females. Clinical features depend upon the location of the tumour, its size, and the presence of metastases. Right colon cancer The usual presentation s vague with anaemia, weakness and loss of weight (Anaemia, Anorexia, Asthenia). The patient may present with recurrent attacks of pain in the right iliac fossa.*
3. A hard mass may be present in the right side of the abdomen. It is differentiated from appendicula mass by the long duration and absence of toxaemia and tenderness (differential diagnosis of a mas in the right iliac region). 4.The patient does not present by intestinal obstruction as the lesion is usually of the cauliflower variety. the contents are liquid and the lumen of the colon is wide. Obstruction occurs, rarely, if obstructs the ileocaecal valve.
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Carcinoma of the sigmoid colon In addition to symptoms of intestinal obstruction, a low tumour may give rise to a feeling of the need for evacuation, which may result in tenesmus accompanied by the passage of mucus and blood. Bladder symptoms are not unusual and, in some instances, may herald a colovesical fistula.
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Carcinoma of the transverse colon This may be mistaken for a carcinoma of the stomach because of the position of the tumour together with anaemia and lassitude. Carcinoma of the caecum and ascending colon This may present with the following: anaemia, severe and unyielding to treatment; the presence of a mass in the right iliac fossa; colonoscopy maybe needed to confirm the diagnosis; a carcinoma of the caecum can be the apex of an intussusception presenting with the symptoms of intermittent obstruction
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complications intestinal obstruction occurs in 20% of cases particularly with left colon tumours. This tendency is attributed to: The smaller lumen of the left colon. Stool tends to be more solid. Carcinoma tends to be of the stenosing variety. Perforation or the formation of an enterocolic or vesicocotic fistula. Bleeding. Chronic bleeding is the rule. Massive bleeding is rare. Complications due to spread, e.g., jaundice, liver failure, and ascites.
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Methods of investigation of colon cancer
Flexible sigmoidoscopy Colonoscopy :- This is now the investigation of choice if colorectal cancer is suspected provided the patient is fit enough to undergo the bowel preparation. Radiology :- Double-contrast barium enema is used when colonoscopy is contraindicated*
Treatment Preoperative preparation Carcinoma of the caecum Carcinoma of the caecum or ascending colon is treated when resectable by right hemicolectomy
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Carcinoma of the hepatic flexure When the hepatic flexure is involved, the resection must be extended correspondingly
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Carcinoma of the splenic flexure or descending colon The extent of the resection is from right colon to descending colon. Sometimes, removal of the colon up to the ileum, with an ileorectal anastomosis, is preferable. Carcinoma of the pelvic colon The left half of the colon is mobilised completely
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