Surgical Pathology of the Small Bowel PDF

Subscribe to DeepL Pro to edit this document. Visit www.DeepL.com/pro for more information. SURGICAL PATHOLOGY OF THE SMALL BOWEL Prof. Dr. Dorel Firescu  Elements of small bowel anatomy Small intestine: is the segment of the digestive tract: ♦ cranial- of pylorus; ♦ caudal- ile...

Subscribe to DeepL Pro to edit this document. Visit www.DeepL.com/pro for more information. SURGICAL PATHOLOGY OF THE SMALL BOWEL Prof. Dr. Dorel Firescu  Elements of small bowel anatomy Small intestine: is the segment of the digestive tract: ♦ cranial- of pylorus; ♦ caudal- ileocecal valve; has an intraperitoneal disposition;  three segments are described: ♦ duodenum; ♦ jejun; ♦ ileon;  jejuno-ileon is 4-7m long of which: ♦ fasting: ¤ is 2/5; ¤ with horizontal arrangement of loops; ♦ ileum: ¤ is 3/5; ¤ with a vertical arrangement of loops;  jejuno-ileon occupies the visceral submezocolic and retroepiploic space: is fixed to the rear wall by a mezenter which: ♦ has an implant base = fixed margin = root; ♦ 15-18 cm long; ♦ extends from the left of the L2 vertebra to the level of the ileocecal valve;  the free edge is where the intestine is inserted; ♦ is longer than the fixed one; ♦ gives the appearance of a wide open fan; the peritoneum envelops the mesentery by reflecting the parietal one; covers the intestine all over;  less on the one where the mezenter= mesosthenic edge is inserted; mesentery = carrier of blood vessels represented by: ♦ superior mesenteric artery - branch of the aorta; ♦ Superior mesenteric vein- drains into the portal vein;  inside the mesentery the vessels are: ♦ arranged in arches (1-5 series of arches); ♦ are parallel to: ▫ base of the mesentery; ▫ small intestine; ♦ are connected by Dwight's right- hand vessels;  these straight vessels eventually reach the intestine; realizes terminal irrigation. there is a single row of arches at the ends: ♦ near the iliocecal valve; ♦ of the duodeno-jejunal angle; near the iliocecal valve = Treves avascular zone; PARACLINICAL MEANS OF EXPLORATION Radiologic - can be: standard examination: with fractionally administered barium; follow its progression in the intestine;  hypotonic duodenography uses glucagon="temporary paralysis of the duodenum; favors visualization of the duodenal mucosa; refers only to the duodenum;  enteroclazis represents intubation and infusion of the small bowel with contrast; necessary for pathology below the Treitz angle; allows identification of small tumors; can identify the site of intestinal bleeding in 20% of cases;  Abdominal computer-tomography: is a widely used method; allows diagnosis of tumor formations in 97%; allows differentiation: - benign ≠ malignant forms;  Positron Emission Positron Emission Tomography (PET): aims to visualize the metabolism accentuated by glycolysis specific to neoplastic tissue; is used mainly for local relapses; has two limits: ▪ cannot differentiate: ¤ malignant tissue/acute inflammation; ¤ invasion into neighboring tissues;  Endoscopy endoscopic methods are used: ► Push endoscopy = push endoscopy; uses: ▪ a lung endoscope; ▪ a pediatric colonoscopy; ▪ examine the small intestine from the Treitz angle; ► Endoscopic probe: - uses a small endoscope; - does not allow biopsy but only visualization; ► Percutaneous endoscopy ▪ can be: ▫ anterograde - access is through the stomach; ▫ retrograde - access is by check;  Arteriography: in case of bleeding in the intestinal lumen; visualization of the contrast substance in the intestinal lumen; Ultrasound; NMR: use less due to intestinal gas; Diagnostic laparoscopy SURGICAL PATHOLOGY OF THE SMALL BOWEL Prof. Dr. Dorel Firescu  SMALL BOWEL DIVERTICULA Diverticulii are: small round or oval bags; formed from extensions of the intestinal wall; pediculate or sessile; in communication with the intestinal lumen; can occur at any level of the digestive tract;  can be categorized into: Congenital diverticula more common in young people; are usually solitary; are located at any point of the intestinal circumference;  the wall is made up of all wall layers: ¤ mucous; ¤ submucous; ¤ muscle; ¤ serious; also called true diverticuli; Acquired diverticulitis: are less common in young people,  their frequency increases with age; located predominantly on the mesostenic edge; usually multiple; with the wall consisting only of: ¤ mucous; ¤ serious; Pathophysiology occur through weaknesses in the structure of the intestinal wall (at the level of the penetration of the blood vessels); associated with increased endoluminal pressure; with advancing age =" weakening of the muscle layer; the gaps widen; allow herniation of the intestinal Clinical picture symptomatology-absent in most cases; the diagnosis is usually made incidentally: ▪ radiologic - for other intestinal distress; ▪ surgical-intraoperator;  clinical distress becomes manifest when complications arise: ♦ inflammatory = diverticulitis ▫ occurs by exacerbation of stagnant intestinal flora in the diverticulum; ▫ evolution is towards: - abscess =" perforation in the peritoneal cavity =► acute generalized peritonitis; ♦ diverticular hemorrhage characterized by massive bleeding; ♦ occlusion which can be: ▫ true; ▫ psudoocclusion; ♦ intestinal absorption disorders; Treatment in asypomatic forms - no treatment; in case of complications =" treatment is surgical: ▫ consists of enterectomies + anastomoses in various assemblies; Meckel's Diverticulum is an embryonic remnant of the omphalomenteric canal; is the most common true diverticulum of the intestinal tract; Occurs on the antimesosthenous border of the terminal ileum; occurs about 40-100 cm from the ileocecal valve; with lengths between 8 and 12 cm (after Angelescu);  contains a mucosa identical in structure to the ileum, Sometimes there are islands of ectopic mucus: ▪ gastric; ▪ pancreatic; ▪ duodenal; which often betrays the existence of diverticulitis; causes non-specific symptoms; Symptomatology in most cases it is asymptomatic; is a chance discovery: ▪ intraoperative; ▪ autopsy;  rarely can we have: ▪ pain: - with periumbilical localization; - more commonly on the left side; ▪ presence of a palpable mass located subombilically;  complications of this type of diverticulitis are: – hemorrhage; – inflammation; – obstruction; – the presence of Meckel's diverticulum in a hernial sac (Littré hernia); Treatment ♦ in asymptomatic cases - treatment is not necessary ♦when an uncomplicated Meckel's diverticulum is discovered during a laparatomy with a different objective: ▪ some recommend abstinence; ▪ others ablation - to prevent further complications; ♦ Important: if surgery is performed in a patient in whom the preoperative diagnosis was acute appendicitis and intraoperatively the appearance of the appendix does not explain the clinical phenomena, it becomes mandatory to unroll the last ileal loops to identify possible complications of a Meckel's diverticulum.  INFLAMMATORY DISEASES Crohn's disease is a granulomatous disease of the intestinal tract; has unknown causes; is characterized by inflammation: ▪ predominant submucosa; ▪ with extension to mucosa and serosa; ▪ presenting transmural character;  mucosal ulceration is accompanied by: ▪ a disproportionate conjunctive reaction; ▪ =>>> intestinal lumen stenosis; ▪ associated with fistula formation;  different terms have been used to describe the disease: ▪ granulomatous enteritis; ▪ transmural enteritis; ▪ Regional ileitis; Epidemiology ♦ the most common small bowel disorder; ♦ Crohn's disease particularly affects: white race; young adults in the third decade of life; a slight predominance in urban women; Etiopathogenesis the mechanism of the disease is not known; a number of factors are incriminated: ▪ genetic; ▪ infectious; ▪ immunological; ▪ environmental factors; ▪ vascular, e.t.c.;  genetic factors - in families with many affected members : ▪ a locus in the centromeric region of chromosome 16; infectious factors: ▪ microbacteria; ▪ viruses; ▪ the infectious factor intervenes only secondarily; ▪ grafts on the lesions;  immunologic component: ▪ is the occurrence of extraintestinal manifestations: ▫ cholangitis; ▫ uveitis; ▫ arthritis; ▪ autoimmune manifestations - can be treated immunosuppressively; Morphopathology ♦ 90% of cases affect the terminal ileum; ♦ intraoperatively the bowel appears: like a rigid tube; irregular; with greatly thickened walls; stenosed lumen; ♦ initial lesions: localized in the submucosa; in the form of aphthous ulceration; ♦ at a more advanced stage: ulcers progress intramurally; obstruction of lymphatic vessels occurs; enlargement of the mesenteric lymph nodes; ♦ further lesions progress to serous: causes the loops to stick together; with the formation of inflammatory pseudo-tumors; fistulas occur by: overcoming the intestinal wall; with progression to neighboring viscera: ▪ colon; ▪ bladder; ▪ small bowel segment - anteriorly unaffected; Microscopic ♦ is different depending on the stage of the disease; ♦ initially in the stage of aphthous ulceration: mucosal and submucosal edema; ♦ stage of complete transmural inflammation: edema; hyperemia; hyperplasia of follicles; ♦ in the final stage: stage of development of giganto- cell granuloma; ▪ also known as Crohn's granuloma; ▪ is the characteristic feature of this disease;  ▪ nodular aggregate of cells appears: epithelial; Langhans-type polynuclear giant cells; surrounded by a crown of lymphoplasmacytes; with a hyaline center; ▪ differs from tuberculosis by: -Loss of centralheating; Symptomatology ♦ the onset is insidious; ♦ slow-onset; ♦ with periods of exacerbation; ♦ interspersed with partial remissions; ♦ never complete calm; ♦ pain - the most common symptom: cramping at first; subsequently persistent; localized mainly in the lower abdomen; ♦ diarrhea - the next most common symptom; present in 85% of cases; ♦ fever: occurs in 1/3 of patients; ♦ weight loss; ♦ physical asthenia; ♦ general discomfort; ♦ complications: occlusion: ▪ caused by progressive narrowing of the lumen; ▪ can be partial or total; perforation: ▪ less often in the free peritoneal cavity due to adhesions;  infectious complications: ▪ abscesses; ▪ fistulas: - entero-cutanate; - entero-vesical; - entero-enteral; - entero-colice; - perineal;  general complications: ▪ malabsorption; ▪ general infectious; ▪ immune-mediated syndromes: - polyarthritis; - erythema nodes;  Diagnostic Clinic patients with long-lasting episodes of: ▪ abdominal pain; ▪ diarrhea; ▪ weight loss;  radiologic diagnosis: ► standard examination ♦ with fractionated barium; ♦ follow its progression in the intestine; ♦ with serial x-rays;  ► enteroclazis: ♦ intubation and infusion of the bowel with contrast; ♦ allows exploration of the bowel from the Treitz angle; ► barium enema (irigography): ♦ may highlight the terminal ileum when there is incompetence and rigidity of the ileocecal valve;  endoscopic diagnosis: ♦ is increasingly used; ♦ provides important diagnostic data; ♦ highlight: ▪ aphthous-granular ulcers; ▪ surrounded by apparently normal mucosa; ▪ more often as the disease progresses; ▪ ulcerations are heterogeneous; ▪ give the appearance of river stone; Treatment ♦ Healing is not possible with either medical or surgical therapy; medical treatment: is indicated during acute exacerbations of the disease:  covers two aspects: symptomatic treatment is addressed: ▪ fight abdominal pain; ▪ diarrhea control; ▪ correction of nutritional deficiencies; ▪ treating the infection;  pathogenic treatment: ▪ no treatment if the etiology is unknown ▪ is used more empirically: ¤ sulfasalazine; ¤ 5-aminosalicylic acid; ¤ immunosuppressants; ¤ antibiotics;  Surgical treatment is only shown in: ▫ late stages of the disease or ▫ failure to respond to medical treatment or ▫ short and only partial response or ▫ in the complications phase of the disease;  interventions can be performed in emergency as well as scheduled; programmed interventions: ▫ the optimal time corresponds to the calm phases; ▫ preceded by in-hospital medical treatment aimed at: ▪ biological restoration; ▪ soothing functional bowel disorders;  the operating techniques used are: ♦ bypass (short-circuiting); ▫ used when general or local conditions preclude primary resection in patients: ▪ biologically calibrated; ▪ with multiple, staggered stenoses; ♦ ileostomy use: ▫ when resection and anastomosis would be risky; ▫ to protect a precarious anastomosis; ♦ resection (enterectomy): is practiced for the intestinal segment involved in the complication; the adjacent obviously affected bowel areas are ignored; the resection limit varies between 2 cm  5-7 cm from the margins of macroscopic lesions; ♦ stricturoplasty (enteroplasty): is a conservative technique; avoid resections; Prognosis The disease prognosis remains poor because of the risk of complications, which can occur even with well- managed treatment. Prophylaxis ♦ is limited to providing maintenance treatment; ♦ aims to prevent further relapse;  INTESTINAL TUBERCULOSIS T.I = the manifestations that occur as a result of specific tuberculous developments in the intestine; can occur at any level of the gastrointestinal tract; occur predominantly in: ▫ small intestine; ▫ in its terminal portion (ileocecal region); ▫ richer in lymphatic formations;  most commonly affected are: ▫ the elderly; ▫ alcoholics; ▫ immunodepressants; ▫ HIV-positive patients; Etiopathogenesis can be of two kinds: primitive: ♦ without an existing lung lesion; ♦ is rare; ♦ resulting from contamination with bovine Koch's bacillus from eating food that gets into the gut such as: ▫ milk; ▫ meat, e.t.c.  secondary ♦ is the most common; ♦ is achieved by swallowing your own sputum from overt tuberculosis of the respiratory tract; or an extinguished pulmonary lymph node outbreak from which it can spread by the : blood; lymphatic; Morphopathology ♦ initially the tubercular process is localized in the lymph follicles; ♦ Granulations are formed, leading to caseation and ulceration; ♦ three morphological categories are recognized: 1. ulcerative form ▫ localizes to the small intestine; ▫ is the most common (approx.60%);  ▫ ulcers are: ▪ of form: - lenticular; - oval; ▪ with mood: - transversal; - or longitudinal along the axis of the intestine; ▪ slow-growing; ▪ with progressive onset of a peritoneal proliferative-inflammatory reaction; ▪ perforations in the peritoneal cavity are rare; ▪ the vessels near the ulceration thromboses which explains the rarity of bleeding; 2. the hypertrophic (sclerolipomatous) form is characterized by: ▪ a process of hyperplastic neoformation; ▪ inflammatory; ▪ well localized; ▪ starts in the submucosa with: variable sizes; irregular surface; mobile for a long time; favoring its surgical removal; 3. ulcero-hypertrophic form ▪ specific to this form is: a peritoneal reaction that forms a plastron; having the appearance of an irregular fibrocystic fibrous block; that can abcess; causes intestinal fistulas; Clinical signs These can be grouped into: General signs ▫ bacillary impregnation syndrome; ▫ with insidious and long-lasting onset; ▫ characterized by: - alteration of general condition; - pallor; - weight loss; - underfebrile; - intermittent febrile periods; Local signs - manifested by: ▫ pain: chronic; deaf; embarrassing; colic in the affected area; ▫ diarrhea: abundant stools; dysenteriform appearance; dark in color; with pronounced putrefaction; rarely with fermentation;  ▪ Objective examination in advanced stages: ▫ the skin appears pale, dirty, pigmented; ▫ at abdominal level we sometimes notice:  a slight meteorism;  in severe cases: ▪ excavated abdominal wall; ▪ with dehydration; ▪ with cadaveric appearance; ▪ with a slight muscular defense when peritoneal disseminations occur; Positive diagnosis The diagnosis requires:  laboratory tests ▪ inflammation tests (elevation of ESHV, C-reactive protein, etc.) are of indicative value; ▪ the tuberculin test is of little help; ▪ the presence of BK in the stool does not prove intestinal tuberculosis because it can accidentally get into the intestine either by swallowing or by bile excretion;  paraclinical explorations: ▪ radiologic examination shows:  rapid bowel transit;  with signs of intestinal irritation; ▪ radiologic signs of intestinal tuberculosis are:  rapid transit;  multiple stenosis;  sometimes images of ulcerations; ▪ CT scan may show: thickening of the intestinal wall; significant regional adenopathy; ▪ colonoscopy allows: Direct visualization of lesions; biopsy;  The definitive diagnosis of tuberculosis is established by: identification of the pathogen (BK) by: ▫ Direct view; ▫ tissue cultures;  Progress and complications the most common complication: ▫ intestinal stenosis with subocclusion or completeocclusion; rare complications: ▫ perforations; ▫ bleeding; ▫ fistulizations; Treatment tuberculostatic treatment: consists of a combination of three antibiotics: ▪ isoniazid; ▪ ethambutol; ▪ rifampicin;  surgical treatment: frequently used in the past; has greatly decreased in scope; is now used to treat complications;  SMALL BOWEL TUMORS are rare; account for 1%-5% of all digestive tract tumors; the small intestine has a remarkable resistance to making benign or malignant tumors; the highest frequency occurs in the ileum;  BENIGN TUMORS are more common than malignant; most arise from the inner tunic of the intestine; their development is almost always towards the intestinal lumen;  Etiology is unknown; can occur in genetic diseases: ▫ intestinal polyposis; ▫ Gardner syndrome;  Pathologic anatomy can meet: -adenoame, -leiomioame, -fibroam, -lipoame, -hamartoma (Peutz-Jeghers syndrome), e.t.c. I. adenoma comprises three forms: - polypoid adenoma; -adenoma of the Brünner glands; -insular adenoma; ▫ polypoid adenoma - with 2 forms: 1.- tubular adenoma = adenomatous polyp; ▪ unique: ▪ multiple ▪ is the most common variant ▪ has malignancy potential 2.- villous adenoma = villous polyp. ▫ Brünner gland adenoma: ▪ localized especially in the duodenum; ▪ without malignancy potential; ▪ does not require large bowel resection;  ▫ insular adenoma represents: either a heterotopic development; either metastatic pancreatic islets; ♦II. leiomyoma develops from the smooth muscle layers of the intestinal wall: ♦ from the submucosa muscle: ▪ have intraluminal proliferation; ▪ determines: ▫ occlusion by invagination or complete blockage; ▫ hemorrhage; ♦ from external muscles ▪ can reach large sizes; ▪ can be palpated; ▪ is complicated by bleeding; ♦III. fibroid is a proliferation of connective tissue; has development in the submucosa; can degenerate malignant; ♦IV. lipoma is localized mainly in the distal ileum; usually is: ▪ a single lesion; ▪ localization in the submucosa; ▪ small; ▪ with chance discovery; ▪ without malignancy potential; ♦V. hamartomul= hamartomatous polyps.are growth malformations -single or multiple -10% associated with Peutz-Jeghers syndrome -constant in the association: intestinal polyposis (hamartomas) + melanin pigmentation of the face (especially perioral) +  lesions being: ▪ small spots; ▪ 1-2 mm; ▪ brown or blackish; is an autosomal dominant inherited syndrome with high penetrance; hamartomatous polyps do not have malignant potential;  in contrast, patients who suffer from this syndrome are at high risk of developing a carcinoma of: ▪ pancreas; ▪ Breast; ▪ earth; ▪ ovary; ▪ uterus; ♦VI. benign neurogenic tumors from the neural elements of the intestinal wall; is in the form of: 1. Schwanoame develops from Schwan's sheath of nerve fibers of the intestine;  2. Ganglioneuroma -develops from intestinal sympathetic ganglia; 3. Neurofibroma -develop from the nerve fibers of the intestinal wall;  can develop: ▪ endoluminal - smaller in size; ▪ exoluminal - can reach larger sizes that can sometimes become palpable; VII. benign vascular tumors ♦1. hemangioma is caused by blood vessel proliferation; is the most common benign vascular tumor; its development is intraluminal; has polypoid appearance; it can ulcerate; causes bleeding or transit disorders; ♦2. lymphangioma is caused by proliferation of the intestinal lymphatic network; presents as: -small formations, -singular, -localized on any intestinal segment; Symptomatology of benign tumors manifests itself through complications pain: ▪ is intermittent or continuous; ▪ occurs when inflammatory processes or ulcerations or obstructions occur; the most common complications are:  Intestinal obstructions ▫ the presence of the tumor favors invaginations of the intestine especially at the level of the terminal ileum and cecum; ▫ repeated subocclusion accidents occur which:  gives in by itself or  require surgery; Intestinal bleeding ▫ occurs by necrosis; ▫ when a major vessel bleeds => massive bleeding may occur; NB.▫ repeated intestinal hemorrhages that cannot be explained by the usual causes (ulcer, liver cirrhosis, e.t.c.) allow the suspicion of an intestinal tumor process; ▫ leiomyoma is the most common cause; Intestinal perforations ▫ are exceptional cases; ▫ are required by the signs of acute peritonitis; Malignant degeneration ▫ is theoretically possible; Diagnostics the diagnosis is probable; results from the complications mentioned above; in few cases a preoperative diagnosis can be established;  dg is confirmed by surgery; the diagnosis of malignancy or benignity is obtained only by anatomic- pathologic examination; Treatment treatment is surgical only; adapted to the particularities of each case; is in relation to: ▪ expansion; ▪ multiplicity; ▪ complications;  MALIGNANT TUMORS can be:  primitive;  secondary;  by histologic appearance can be:  epithelial = epitheliomatous;  of conjunctival origin = sarcomatous; Clinical aspect signs common to all malignant tumors: – Change in general condition: ▫ occurs after a fairly long latency period; ▫ with an insidious development; – Pain - can be in the form of : ▫ colic; ▫ persistent embarrassment; ▫ epigastric burning;  – Febrile periods: ▫ intermittent, ▫ may occur in case of: ulcers, superinfections; – Weight loss: ▫ draws attention to the patient; – Occult bleeding ▫ lead to anemia, ▫ can be quite severe;  Bowel obstruction ▫ can be installed: ► suddenly - through intussusception; ► with pre-cogenic stenosis: ▫ develops slowly, progressively; ▫ with alternating constipation/diarrhea; ► accompanied by: ▫ bloating; ▫ localized meteorism; ▫ hydroaeric noises;  Perforations ▫ are rare; ▫ occur less suddenly; specific signs:  are variable in relation to: ▫ nature; ▫ volume; ▫ localization; ▫ the mode of evolution; Clinical diagnosis objective examination is usually negative; provides little information; sometimes a formation can be palpated in leiomyomas; Treatment surgical - can be: – curative - surgery = resection of the tumor + lymph node stations: ▫ when the tumor has a local stage: -without overcoming the intestinal serosa; -without lymph node invasion and distant metastases;  – palliative : ▫ when the tumor is unresectable; ▫ in purpose: reducing complications (hemorrhagic, occlusive, e.t.c); to ease the patient's suffering;  radiotherapeutic; Chemotherapeutic; ► radiotherapy and chemotherapy: ▫ are not used as primary treatments in intestinal tumors; ▫ can be used as an adjuvant treatment after surgery, especially for sarcomas; I.Adenocarcinoma  accounts for about 50% of all intestinal malignancies;  is twice as common in men as in women;  with localization mainly in the proximal intestine;  tumor starts from: ▫ mucous; ▫ from an adenomatous polyp; fenomenele are characterized by: ▫ progressive alteration of general condition; ▫ no obvious local phenomena; ▫ with epigastric embarrassment; ▫ bloating and pain;  evolutionary: ▫ the signs increase in intensity; ▫ is installed:  anemia;  mane;  an acute occlusive stroke;  in advanced stages: ▫ the tumor may become:  palpable;  furniture; ▫ may develop adhesions with the omentum; ▫ can fistulize in:  colon;  other abdominal organs;  metastasizes: ▫ in the mesenteric lymph nodes; ▫ in the liver; tratamentul is: ► surgical: ▫ segmental resection within oncologic limits, 10 cm from the tumor margin; ► chemotherapeutic;  prognosis is: ▫ favorable in cases diagnosed and treated early; ▫ reserved in cases diagnosed late: -with liver and lymph node metastases; -in the complications phase: occlusive-perforative complications; II. Sarcome  can occur at any age;  is the starting point: ▫ muscle tissue = leiomyosarcoma ▫ lymphatic tissue = lymphosarcoma  leiomiosarcomul: ▫ is the most common sarcoma; ▫ is evenly distributed throughout the small intestine; ▫ has an equal incidence between men and women; ▫ can develop: in the muscularis mucosae: with proliferation to the intestinal lumen; causes mucosal ulceration; produces bleeding that varies in intensity;  from the outer muscle layer: with development towards serous; can sometimes reach important dimensions;  macroscopic tumor is: ▫ sea; ▫ whitish; ▫ per section has areas of hemorrhage and necrosis;  metastases occur: ▫ by blood; ▫ rarely lymphatically; III. Malignant vascular tumors 1.Hemangioendoendothelioma - consists of endothelial cell masses. It metastasizes early so surgery is required; 2.Benign metastatic hemangioma - although it is histologically benign, it is classified as a malignant vascular tumor, with the potential for lymph node metastasis;  3.Angiosarcoma - is characterized by masses of endothelial cells with atypia and anaplastic character. 4.Kaposi's sarcoma - multiple lymphoma - is a predominantly cutaneous disease, affecting the intestine in about 10% of cases;  5.Hemangiopericytoma - is a tumor formed by numerous capillary ducts, surrounding or including masses of epithelial cells. -may also occur in the intestine  VI. Malignant lymphoma ♦represents about 10-15% of malignant small bowel tumors, ♦predilect localization on the ileum - high concentration of lymphoid tissue ♦can be : primary -are rarer, conditions: –no superficial adenopathy; –not to have a widened mediastinal view: ▪ chest X-ray ▪ or CT; –the blood formula is normal; –free of hepato and splenomegaly. Secondary are the most common, histologically these lymphomas can be: ▫ hodgkin's, ▫ non-hodgkin's , by studying markers on the cell surface they can be: ▫ B-cell and may be of type: -western; -Mediterranean. ▫ T-cell  Western-type non-hodgkin's lymphoma present as tumors: ▪ single or multiple, ▪ located on one or more intestinal segments, ▪ at a distance from each other, ▪ separated from normal mucosa.  Mediterranean-type non-Hodgkin's lymphoma: ♦ is an immune-proliferative form of the intestine, ♦ no areas of normal mucosa, ♦ hence the severity of the disease. Clinical picture ♦symptomatology common to malignant tumors: ▪ abdominal pain (colic or dull ache), ▪ weight loss, ▪ nausea, ▪ vomiting, ▪ abdominal distension, ▪ diarrhea, ▪ occult bleeding. Treatment ♦ relies on surgery: resection of the affected segment with regional lymphadenectomy ♦ radiation therapy, ♦ chemotherapy = treatment of choice.  Small bowel carcinoid ♦are neuroendocrine tumors, ♦ develops from chromaffin cells, ♦predominantly on the small intestine, ♦belongs to the A.P.U.D. (amine precursor uptake and decarboxylation) system. Epidemiologic ♦predominantly occur in your 60s, ♦more common in men, ♦especially in the black race, ♦more commonly localized at: appendix, small intestine, right. Pathologic anatomy. ♦Macroscopic tumors are small, with a diameter less than 2 cm, originate in the cells of the Lieberkühn glands ♦Microscopic are made up of: small cells, ▪monomorph, ▪rarely seeing mitoses in the nuclei of tumor cells. depending on their ability to reduce silver salts, they are divided into: ▫argentafine=argentafinoamines - reduce silver salts; ▫argirophiles=argirofinoamines - ♦peritumoral is seen: an expanding fibrosis reaction: ▫to the intestinal lumen, ▫spre serosa, invade: ▫peritoneum, ▪meenter, consequence= intestinal plicaturation=" subolucency or total occlusion the changes are due to serotonin secretion. in advanced cases in the process of fibrosis can be caught intestinal vascularization = "ischemic phenomena. Pathophysiology. ♦is produced by the tumor's release of: serotonin - secreted by: - enterochromaffin cells, -CNS and peripheral system, ▪by metabolizing tryptophan. ▪ In healthy individuals, little tryptophan is converted into serotonin, ▪in patients with carcinoid tumors ≤ 60% tryptophan is transformed  ▪ serotonin actions are: ▫produces cardiovascular changes: -extrystole, -tachycardia, -voltage changes, ▫scade renal flow, ▫have fibroblastic action on the serosa. other substances released: ▪calicreines, ▪catecholamines, ▪histamine, ▪ motilin. Clinical picture tumor syndrome -the following signs appear: abdominal pain, ▪is the most constant symptom, ▪is non-specific, ▪ make an accurate topography, ▪ may be accompanied by subacute syndromes; diaarrhea, ▪considered secondary to increased serotonin, ▪as a result of increased intestinal motility, ▪may precede the classic clinical manifestations of the disease. carcinoid syndrome: skin flush, ▪considered the most characteristic symptom, ▪ manifests itself by: ▫ bright red discoloration of the fleece, ▫localized at level: -face, -neck, -the previous thorax;  bronchial involvement; cardiovascular disorders, consisting of: ▫ blood pressure changes (hypotension), ▫extrasystoles; mental instability, translated as anxiety, neurosis; hepatomegaly. Diagnosis. ♦standard barium radiologic examination of the bowel - can visualize: filling defects due to: ▪ either tumor formations, ▪ either fibrosis of the bowel. ♦ irigography can retrogradely highlights tumors of the terminal ileum; ♦ ultrasound examination can detect the formation larger than 1.5 cm in diameter, can assess the degree of tumor infiltration, is useful in determining metastatic processes: ▪hepatic, ▪peritoneal, ▪adenopathies; ♦computed tomography and magnetic resonance imaging (MRI) scan not superior to ultrasound in tumor detection, are useful in assessing the extent of disease; ♦ lower digestive endoscopy (colonoscopy) can retrogradely visualize the terminal ileum; Evolution. carcinoid has a slow progression, survival duration > other histologic types of IS tumors specific symptomatology appears late, not always being characteristic, diagnosis is delayed, often untimely Treatment can be: surgical ♦represents the treatment of choice, ♦involves in the elevation of tumor formations as well as liver metastases. ♦can be done: in emergency (bleeding, occlusive phenomena), elective intervention. chemotherapy ♦used as an adjuvant treatment, ♦ combinations are made between different cytostatics,  Immunotherapy ♦used as an adjuvant effect to reduce symptoms, ♦ effects decrease: ▪ skin flush, ▪a diarrhea, ▪ bronchospastic episodes, ▪ in about 20% of cases a tumor regression. STROMAL TUMOR