Endoscopic signs of duodenal tumors

Benign tumors of the duodenum

Primary tumors of the duodenum are extremely rare - 0.009%.

Classification of benign tumors of the duodenum.

Zollinger-Ellison syndrome.

1. Tumors of epithelial origin:
   • adenomas,
   • hyperplasiogenic polyps.
2. Nonepithelial tumors:
   • lipomas,
   • neuromas,
   • fibroids,
   • leiomyomas, etc.

Benign tumors can be single or multiple. No preferred localization has been identified. They flow asymptomatically. Clinical manifestations in case of complications (bleeding, obstruction).

Epithelial benign tumors. These include polyps and polypoid tumor changes of the mucous membrane of the duodenum. They have a spherical, mushroom-shaped or lobular shape. They can be, like gastric polyps, on a stalk or on a broad base, easily mobile, soft or soft-elastic consistency, the color is more intense than that of the surrounding mucous membrane, often ulcerate, bleed easily.

True polyps, unlike polypoid and submucous tumors, have a clearly defined base, which can subsequently transform into a stalk. This is explained by the fact that a polyp is an epithelial tumor, while polypoid and submucous tumors are formed by neoplastic tissues covered with epithelium, and therefore cannot have a well-defined base. This diagnostic criterion, however, cannot always be applied due to the great similarity of some submucous tumors (for example, carcinoid) with polyps on a broad base.

A piece of the tumor taken with biopsy forceps is usually sufficient for a biopsy. If the histological picture is unclear, endoscopic removal of the entire polyp is necessary.

Polyps up to 0.5 cm are observed at least once every 6 months, more than 0.5 cm polypectomy is indicated. Biopsy is mandatory, since in 7.4% they develop into cancer. Before polypectomy, it is necessary to determine the relationship to BDS. If the polyp is locatednear the BDS - abdominal surgery is indicated. Submucous (non-epithelial) benign tumors. They are located in the submucous layer, covered with normal mucous membrane, the borders are clear, but the base is not clearly delimited. The shapes are round or oval, a positive tent symptom is noted. The consistency is soft and elastic. If there is an ulcer on the surface of the tumor, a biopsy should be performed through the ulceration or an extended biopsy should be performed.

Malignant tumors of the duodenum

Until 1976, there was not a single case of lifetime diagnosis of duodenal cancer. It accounts for 0.3% of all malignant tumors of the gastrointestinal tract. Primary and secondary cancer of the duodenum are distinguished.

Primary cancer originates from the wall of the duodenum. It is very rare - 0.04%. It is localized mainly in the descending part, less often in the lower horizontal and extremely rarely in the upper horizontal branch of the duodenum. In the descending part, supra-, infra- and periampullary locations are distinguished. The latter is the most common and difficult to diagnose, since it is not always possible to differentiate it from cancer of the papilla of Vater. Metastasis is observed late: first in the regional lymph nodes, then in the liver, pancreas, and later in other organs. Histologically, adenocarcinoma is determined in 80%.

Classification of primary duodenal cancer.

1. Polypous form (exophytic cancer).
2. Infiltrative-ulcerative form (endophytic cancer).
3. Scirrhous-stenotic form (endophytic cancer).

Exophytic cancer. More common. Tumor nodes are gray-red, often with erosions or ulceration at the top. The tumor is clearly demarcated from the surrounding mucosa, there is no infiltration. It can be rigid, but it can also be soft, easily disintegrating, bleeding.

Infiltrative-ulcerative form. An irregularly shaped flat ulcerative defect of bright red color is determined. The bottom is rough, the edges often have protruding papillae. Instrumental palpation reveals rigidity, slight contact bleeding.

Scirrhous-stenotic form. Narrowing of the lumen of the duodenum is noted. The mucous membrane is dull and pale. The relief changes: the surface is uneven, knotty, the folds do not straighten out with air. Instrumental palpation reveals pronounced rigidity. Peristalsis is absent. Contact bleeding is insignificant.

Secondary cancer of the duodenum originates from adjacent organs (germination from the pancreas, ampulla of Vater, bile ducts).

There are 3 stages of the process spread:

• Stage I. Tumor fusion with the duodenal wall. Lumen deformation is slightly expressed (swelling, wall displacement). The mucosa is mobile, unchanged. No fistulas. No intraluminal tumor growth. Biopsy does not give anything.
• Stage II. Tumor growth into the duodenal wall without involvement of the mucous membrane. Persistent lumen deformation. The mucous membrane is fixed, there are inflammatory changes, erosions. There are no fistulas. There is no intraluminal tumor growth. Biopsy reveals inflammatory changes.
• Stage III. Invasion of all layers. Lumen deformation is persistent. The mucosa is fixed, there are tumor tissue growths. There are fistulas. There is intraluminal tumor growth. Biopsy shows cancer.

The diagnosis is reliable at grade III, highly reliable at grade II, and at grade I endoscopic diagnostics is ineffective.

Endoscopic signs of diseases of the organs of the hepatoduodenal zone

Edoscopic signs of chronic pancreatitis, diseases of the biliary system

1. Severe duodenitis of the descending section with changes in the mucosa of the “semolina” type (lymphangiectasia).
2. Coarse folding of the mucous membrane of the postbulbar region.
3. Severe focal duodenitis in the area of the duodenal ulcer, papillitis.
4. Presence of duodenogastric reflux.
5. Deformation, narrowing of the lumen, change in bending angles.

Indirect endoscopic signs of acute pancreatitis

The changes are caused by inflammation of the pancreas and its swelling.

1. 1. Local inflammation along the posterior wall of the stomach and along the medial wall of the duodenum: hyperemia, edema, fibrin deposits, erosions, multiple hemorrhages, an increase in the size of the duodenum, papillitis.
2. 2. An increase in the size of the pancreas causes displacement of the posterior wall of the stomach and the bulb of the duodenum, straightening of the upper duodenal flexure and flattening of the lumen of the descending branch of the duodenum.

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