Small Intestine Diseases / Small Intestine Cancer

It is a congenital, embryonic remnant anomaly of the gastrointestinal tract manifested by the presence of a saccular prolongation/formation in the terminal portion of the small intestine near the junction with the colon. It is a defect of the small intestine resulting from incomplete closure of the omphalomesenteric duct (the connection between the yolk sac and the primitive intestine), measuring about 5 cm.

Most of the time the presence of this Meckel’s diverticulum does not cause symptoms. You may experience symptoms if complications occur, such as:

• Asthenia, fatigue (fatigability), due to an anemic syndrome, in the presence of chronic bleeding from the diverticula
• Presence of blood in the stool (melena)
• Abdominal pain, vomiting, lack of bowel movement, in case of diverticulitis (inflammation), intestinal perforation or occlusion

Often symptoms such as abdominal pain and vomiting can be mistaken for appendicitis.

The diagnosis of Meckel’s diverticulum is often difficult to make. To diagnose Meckel’s diverticulum, the following examinations are needed:
– Upper/lower digestive endoscopy – involves the insertion through the oral cavity or anus of a thin tube (the diameter of a pen) with a camera at the end, which allows the examining doctor to visualize the inside of the digestive tract to exclude digestive bleeding from another level, even if he cannot reveal bleeding from the diverticus
– Abdominal ultrasound – non-invasive, atraumatic ultrasound-based imaging method that allows visualization of free fluid in the abdominal cavity (in case of presence of peritonitis); in some cases, less frequently, inflamed diverticulum can be detected
– Technetium scintigraphy – imaging method that involves intravenous administration of Technetium and can identify the diverticulum
– CT angiography – a state-of-the-art, non-invasive imaging method that combines computer technology with angiography (an imaging technique that visualizes vascular structures by injecting a contrast agent), indicated in cases of digestive bleeding, which can show bleeding from the diverticula
– Endoscopic video capsule – involves swallowing a capsule (the size of a pill that is fitted with a camera); like a pill, the capsule will move through the stomach into the small intestine, during which time it takes thousands of pictures, which are sent to a device that can then be viewed on a computer; the capsule is eliminated physiologically during normal bowel movements
– Blood tests – haemolucogram – (may show anaemic syndrome in case of diverticular haemorrhage), increased leukocyte count (leukocytosis) in case of diverticular perforation peritonitis, increased C-reactive protein (CRP) in case of diverticular inflammation

– In the case of incidental, image-diagnosed, asymptomatic Meckel’s diverticulum, no treatment is required
– If the diverticulum causes symptoms, due to complications such as bleeding, surgical treatment is indicated, which involves resection/ removal of the diverticulum
– If Meckel’s diverticulum is revealed during other abdominal surgeries, its removal is indicated to prevent possible further complications

Benign tumours are non-cancerous tumours, they remain in one place and do not spread to other parts of the body. Also after they are removed they do not reappear. Even if they are not cancerous, they can cause symptoms. Pre-cancerous (pre-malignant) tumours are benign tumours containing abnormal cells that have the potential to turn into cancer if left untreated.

In contrast, malignant tumours are cancerous tumours that develop in nearby tissues, contain cells that can rupture and reach the blood or lymphatic system, thus spreading to lymph nodes and other distant regions of the body.

The most common small bowel malignancies are:

• Adenocarcinoma
• Lymphoma
• Sarcoma, which includes gastrointestinal stromal tumors (GIST)
• Carcinoid tumours (neuroendocrine tumours)

The cause of most small bowel cancers is unknown, although there are certain risk factors that predispose to the development of these cancers.

Risk factors for adenocarcinoma:

• Genetic mutations/abnormal changes in the AND of gastric cells
• Genetic/hereditary syndromes (Lynch syndrome-hereditary non-polyposis colorectal cancer, Peutz-Jeghers syndrome, familial adenomatous polyposis-hereditary diseases in which the large intestine is covered by polyps, cystic fibrosis)
• Colorectal cancer
• Crohn’s disease – inflammation of the small intestine that usually starts in the ileum (the last part of the small intestine)
• Celiac disease/gluten intolerance
• Alcohol
• Obesity
• Smoking
• Diet (high salt foods, smoked meats, red meat, high amounts of sugar)

Risk factors for lymphoma:

• Celiac disease
• Chronic immunodeficiency status, immunodeficiency syndrome (AIDS) or presence of autoimmune diseases
• Long-term immunosuppressive therapy
• Crohn’s disease
• Radiotherapy
• Nodular lymphoid hyperplasia

If a small bowel tumour is present, you may experience the following symptoms:

• Intermittent colicky pain/cramping in the abdomen, usually centrally located
• Nausea +/- vomiting
• Fatigue (tiredness)
• Anaemia
• Blood in stool/dark/black stool (melena)
• Weight loss without apparent cause
• Watery diarrhoea and reddening of the skin (in carcinoid tumours)
• Stopping bowel movements in case of intestinal obstruction

The following investigations may be necessary to establish the diagnosis of a small bowel tumour:
– Upper digestive endoscopy (esogastroduodenoscopy) – involves inserting a thin tube (diameter of a pen) through the oral cavity, through the oesophagus and stomach, up to the level of the duodenum or the first jejunal loop (first part of the small intestine), fitted with a camera at the end, so that the tumour can be visualised directly.
– Biopsy – a manoeuvre performed during upper endoscopy in which the doctor removes a piece of tissue from the small intestine that looks suspicious and then examines it under a microscope.
– Lower digestive endoscopy/colonoscopy – like upper digestive endoscopy, involves the insertion of a tube with a camera at the end, the tube is inserted through the anus, ascends into the colon to the last part of the small intestine
– Endoscopic video capsule – involves swallowing a capsule (the size of a pill with a camera); like a pill, the capsule will move through the stomach into the small intestine, taking thousands of pictures, which are sent to a device that can then be viewed on a computer; the capsule is eliminated physiologically during normal bowel movements; it is indicated only in patients with digestive bleeding, without pathological changes that have been detected by upper and lower endoscopy
– Barium passage – a special type of X-ray that involves swallowing a suspension of barium, allowing radiological visualization of the esophagus, stomach and small intestine
– Computed Tomography (CT) – produces a series of detailed images of certain regions of the body, these images are taken from different planes; for a better highlighting of the explored region, contrast is used which can be administered intravenously or orally (entero-CT); this imaging method is the imaging of choice highlighting the tumor, the changes around it and assesses the remote extension in the case of malignant tumors (detecting possible metastases)
– Positron Emission Tomography (PET) – produces an image that can help detect the spread of cancer cells throughout the body; a radionuclide (glucose) is injected intravenously and an image is obtained that highlights structures that use glucose; neoplastic cells are more metabolically active and use glucose more intensively than normal cells
– Abdominal ultrasound – non-invasive and atraumatic ultrasound-based imaging method that involves visualization of intra-abdominal organs; allows visualization of small bowel tumors if they are large or can detect dilatation of intestinal loops located upstream of the obstacle, fluid in the abdominal cavity
– Exploratory laparotomy – involves surgical exploration of the abdominal cavity by incision of the abdominal wall
– Laboratory tests – haemolucogram (may show an anaemic syndrome in case of haemorrhage from the tumour)

Surgical treatment is indicated for small bowel tumours diagnosed following endoscopic or imaging examinations for specific symptoms. Depending on the type of benign or malignant tumour (diagnosis established by biopsy), a limited segmental enteral resection (for confirmed benign tumours) or a segmental enteral resection with oncological limits, approximately 10 cm proximal and distal to the tumour (for confirmed malignant tumours) is indicated. A segmental enteral resection involves surgical removal of the affected part of the small intestine with suturing (joining) of the two cut ends to restore digestive continuity.

In the case of malignant tumours, depending on their stage, oncological treatment may be indicated:

Chemotherapy

Anti-tumour treatment, which uses certain drugs to destroy cancer cells; it can be given before surgical treatment (neoadjuvant chemotherapy) to reduce the size of the tumour formation so that it can be removed by surgery, or it can be given after surgical treatment (adjuvant chemotherapy) to destroy cancer cells that may already be spread in the body.

Radiotherapy

Anti-tumour treatment, which uses high-intensity X-rays or other types of radiation that are capable of destroying malignant cells; it can be, as with chemotherapy, of two types: neoadjuvant or adjuvant.

Radiochemotherapy

It involves combining chemotherapy with radiotherapy to increase their effectiveness.

Biological therapy/immunotherapy

It uses substances produced by the body or synthesised in the laboratory to strengthen the immune system in its fight against cancer.

Crohn’s disease is a chronic inflammatory disease that presents as ulcerative lesions located in the wall of the digestive tract, which can lead to complications such as fistulas or stenosis (narrowing of the intestinal lumen). It can theoretically affect any segment from the oesophagus to the anus, but with localisation mainly in the last portion of the small intestine (terminal ileitis) and the colon.

If you have Crohn’s disease you may experience the following symptoms:

• Crampy abdominal pain
• Diarrhoea chairs
• Blood in the stool/dark/black stool (melena) in case of chronic GI bleeding
• Weight loss
• Asthenia/ fatigue, altered general condition
• Febrile syndrome

Specific manifestations may occur in case of surgical complications of Crohn’s disease of the intestine:

• Subocclusive/occlusive syndrome in the development of stenosis
• Localised peritonitis/abscess in case of a blocked perforation
• Generalized peritonitis in case of perforationExtrusion of enteral contents (from inside the small intestine) to an area of skin/tissue continuity in case of entero-cutaneous fistula
• Enteral content externalization in the urine in case of entero-urinary fistula, manifested by dysuria (pain or burning felt when urinating), suprapubic discomfort, penumaturia (emission of urine mixed with gas), fecaluria (emission of urine with feces)
• Diarrhoea refractory to treatment + malnutrition in case of entero-enteric/enterocolic fistula with bypass of a long portion of the digestive tract

The following investigations are required to establish the diagnosis of Crohn’s disease in the small intestine:
– Upper digestive endoscopy (esogastroduodenoscopy) – involves inserting a thin tube (diameter of a pen) through the oral cavity, through the oesophagus and stomach, up to the level of the duodenum or first jejunal loop (first part of the small intestine), fitted with a camera at the end, so that lesions can be visualised.
– Biopsy – a manoeuvre performed during upper endoscopy in which the doctor removes a piece of tissue from the small intestine that looks suspicious and then examines it under a microscope.
– Lower digestive endoscopy/colonoscopy + ileoscopy – similar to upper digestive endoscopy involves the insertion of a tube with a camera at the end, the tube is inserted through the anus, ascends into the colon to the last part of the small intestine
– Abdominal CT/MRI with oral contrast (entero-CT/MRI ) – produces a series of detailed images of certain regions of the body, these images are taken from different planes; for a better visualization of the region being explored, the contrast substance is administered orally (entero-CT); it can reveal stenoses, fistulas, thickening of the wall of the small intestine, abscesses, adenopathies
– Abdominal ultrasound – non-invasive and atraumatic ultrasound-based imaging method that involves visualization of intra-abdominal organs; can visualize small bowel distention upstream of a stenosis or pathological collections in the abdominal cavity (abscess, perforation peritonitis)
– Endoscopic video capsule – involves swallowing a capsule (the size of a pill that is fitted with a camera); like a pill, the capsule will move through the stomach into the small intestine, during which time it takes thousands of pictures, which are sent to a device that can then be viewed on a computer; the capsule is eliminated physiologically during normal bowel movements; used for evaluating the bowel not accessible to traditional endoscopy
– Fecal analysis to assess possible blood loss, inflammation or infection
– Laboratory tests – hemoleukogram – (increased leukocyte count – leukocytosis), ESR, C-reactive protein (increased values in the presence of inflammation), immunology pANCAs (perinuclear antineutrophil cytoplasmic perinuclear cytoplasmic antibodies), ASCAs (antibodies against Saccharomyces cerevisiae)

Treatment in Crohn’s disease aims to control inflammation, control nutritional deficiencies and relieve symptoms.

Conservative treatment/ medication

Steroids (anti-inflammatory drugs most often used in the treatment of moderate or severe acute pustules), azathioprine, anti-TNF therapy.

Surgical treatment indicated in the following situations

– Persistence of symptoms or worsening of symptoms with the right medication (more than 6 months)
– Return of symptoms after stopping high-dose corticosteroids
– Onset of complications specific to corticosteroid therapy (secondary Cushing’s syndrome, cataracts, glaucoma, secondary hypertension, aseptic necrosis of the femoral head, myopathies, vertebral fractures)
– Intestinal occlusion through strictures
– Cutaneous, enetero-vesical, entero-ureteral or entero-vaginal, entero-enteral (between different portions of the small intestine) or entero-colic (between the small intestine and the colon) fistula
– Abscess in the abdominal cavity
– Peritonitis through intestinal perforation
– Onset of bleeding
– Suspicion of malignancy confirmed by biopsy (histopathology result)

Depending on the complication, resection of the affected bowel may be indicated (in the case of stenosis obstructing the intestinal lumen with the presence of septic processes, such as abscesses, peritonitis; in the case of perforations, haemorrhages or the presence of malignant transformation), drainage of collections, dissection of the fistula with resection of the affected bowel.
Sometimes it is necessary to perform an artificial opening (stoma) of the small intestine (ileostoma) in the abdominal wall (in cases with peritonitis or marked inflammation, or if you are at increased risk of complications after anastomosis / suture of the ends of the small intestine: low protein, chronic treatment with high-dose corticosteroids), with the possibility of restoring digestive continuity at 3 months postoperatively.