How does itching manifest in Vater's nipple cancer? Treatment
For quotation: Bazin I.S., Garin A.M. Treatment of cholangiocellular cancer of the bile ducts, gallbladder cancer and cancer of the papilla of Vater // Breast Cancer. 2002. No. 24. S. 1103
Russian Oncology Research Center named after. N.N. Blokhin RAMS
General information about anatomy Intrahepatic bile ducts are located in the liver tissue. Among them, bile canaliculi and interlobular bile canaliculi are distinguished. Bile canaliculi, formed from bile capillaries, are located along the periphery of the hepatic lobules. The bile canaliculi become interlobular bile canaliculi; the latter flow into the left and right hepatic ducts. The bile then enters the common hepatic duct. Then the latter, as well as the cystic duct emanating from the gallbladder, pass into the common bile duct (common bile duct). The path of bile ends in the hepatopancreatic ampulla - the diverticulum of Vater, at the junction of the common bile duct and the pancreatic duct.
Cholangiocellular carcinoma of the bile ducts In Russia, there are no statistics on cholangiocellular carcinoma of the bile ducts (CCBC). According to hospital registers, it accounts for 7-8% of malignant neoplasms of the periampullary zone. According to international data, the incidence of biliary tumors varies from 2 to 8/100,000
Among the background diseases that precede the development of chronic bile ducts, an important place is occupied by primary sclerosing cholangitis, congenital dilatation of the intra- or extrahepatic bile ducts, often in the common bile duct (Caroli disease).
The hereditary risk of CCBD is significant: if there were patients with tumors of the biliary system in the family, the risk of developing the same disease in first-degree relatives exceeds the risk for healthy families by 14 times.
Holzinger et al. are considering 4 phases of the pathogenesis of biliary carcinogenesis:
Phase II - genotoxic disorders leading to DNA damage and mutations.
Phase III - dysregulation of DNA repair mechanisms and apoptosis, allowing mutated cells to survive.
Phase IV - further morphological evolution of premalignant cells into cholangiocarcinoma.
The only radical treatment for distal extrahepatic duct cancer is pancreaticoduodenectomy . It is feasible in 2/3 of patients. The results of this operation are better than those for pancreatic cancer (greater resectability, fewer tumor changes at the edges of the incision, less involvement of regional lymph nodes).
The goals of surgical interventions on the proximal bile ducts are to eradicate the tumor and establish adequate bile flow. So radical can be liver resection (lobectomy or removal of several segments). Surgeries are feasible in 40% of cases, postoperative mortality is 8%, median survival varies from 18 to 23 months.
In rare cases, with proximal CCLC, hepatectomy with liver transplantation is performed. The five-year survival rate is 12.5%.
Due to late diagnosis, patients with cholangiocellular intrahepatic cancer are rarely operated on. Radical liver resections are performed only in the early stages.
Hepatectomy followed by liver transplantation for the intrahepatic variant of CCLC leads to a 17% five-year survival rate.
Hepaticojejunostomy or choledochojejunostomy are performed as bile-constructive operations. Most surgeons believe that radical operations for bile duct cancer in icteric patients should be preceded by bile unloading procedures.
Among chemotherapy drugs , tested for CCBC - fluorouracil, mitomycin, epirubicin, doxorubicin, cisplatin, paclitaxel, gemcitabine, capecitabine, UFT, S-1. The drugs were used in combinations, mono regimens, and in combination with radiation therapy. The most studied is fluorouracil. Fluorouracil in the jet injection mode causes 11.4% of partial effects.
The combination of fluorouracil with carmustine or streptozotocin did not exceed the results of monotherapy alone.
The results are impressive when combining high doses of fluorouracil with leucovorin. Weekly 24-hour infusions were used, an immediate effect was recorded in a third of patients, stabilization in another 39% of patients.
The combination of fluorouracil with α-interferon has also been studied in CCBC - the effect was recorded in more than one third of patients.
The combination FU+DDP±EPI was effective with 2 components in 24%, and with 3 drugs in 33%. Stabilization was recorded in another third of patients.
The three-component combination of fluorouracil with leucovorin and carboplatin led to clinical improvement in 49% of cases, an immediate effect was recorded in 21% of cases.
Mitomycin in monotherapy is effective in 22.2% of cases.
The combination of fluorouracil, mitomycin and doxorubicin turned out to be highly effective (although on small clinical material). The effect was achieved in 31% of patients and stabilization for more than 3 months - in another 51% of patients.
Gemcitabine monotherapy also shows activity against this form of cancer. Moreover, the objective improvement was accompanied by a pronounced subjective effect.
The combination of fluorouracil with gemcitabine was effective in 43% of patients.
When fluorouracil was combined with leucovorin, mitomycin and gemcitabine, the effect was noted in 25% of cases and stabilization for more than 6 months in another 30%. The subjective effect was very expressive.
When testing new drugs, attention was drawn to the work of Jones et al., who noted long-term stabilization of the condition of unresectable patients with CCBC after the use of paclitaxel in monotherapy.
The blood supply to the bile ducts is carried out through the hepatic artery system. Attempts have been made to administer intra-arterial mitomycin and fluorouracil. The effect was recorded in 60% of patients, the median survival was slightly more than a year.
Among the new drugs that have shown activity in monotherapy are capecitabine (16% effect, time to progression 7 months, one-year survival - 70%), fluorouracil modulators - UFT, S-1, eniuracil.
There is known experience with chemoradiation therapy for unresectable CCBC. When intraluminal irradiation (20 Gy) was combined with external irradiation (48.5 Gy) and long-term infusions of fluorouracil, the median time to progression was in the observations of Desai et al. 16.3 months, and median survival - 25.8 months.
There is still a certain trend towards improving the results of treatment of cholelithiasis in the world. In Europe in 1978-80. 20% of patients survived 1 year, in 1987-89. - 29%, and 5 years, respectively, these years are 11 and 14%.
Gallbladder cancer In Russia, gallbladder cancer (GC) is registered annually in 2800 patients. Gastric cancer ranks 5th in mortality from tumors of the digestive system, is registered in the 6th and 7th decades of life (average age 73 years), 2 times more often in women.
Predisposing factors for gastric cancer include cholelithiasis, calcification of the gallbladder walls, abnormalities in the structure of the bile ducts, and obesity. The linear relationship between excessive body weight and the risk of gastric cancer has been confirmed in epidemiological studies.
GC refers to early and rapidly disseminating tumors . There are 4 known ways of generalization of tumor cells:
- Direct invasion of neighboring organs, and primarily of the liver (segments IV and V). The ease of invasion is facilitated by the thin wall of the gallbladder (one muscular layer).
- Lymphogenous and hematogenous metastasis begins with penetration of the muscle layer, where the tumor comes into contact with numerous lymphatic and blood vessels. At autopsies, lymphogenous metastases are detected in 94%, and hematogenous metastases in 65% of cases.
- The 4th route of metastasis is peritoneal.
Figures from population and hospital registries on the total survival rate of all patients with gastric cancer are extremely unfavorable: 5-year survival rate - 5%, median survival rate - 5-8 months.
Surgical strategy depends on the stage of gastric cancer. Stage I patients survive 5 years in 85-100%. A standard cholecystectomy is considered an adequate operation.
At T2, simple cholecystectomy can also be performed, with 5-year results of 40.5%. There are objections to performing such an operation, since T2 often reveals metastases in regional lymph nodes and in 12% peritoneal metastases. The effectiveness of extended cholecystectomy at stage II reaches 80-90%. Extended cholecystectomy includes wedge-shaped resection of the gallbladder bed and regional lymph nodes from the hepatoduodenal ligament. If the bile ducts are removed, hepaticojejunostomy is performed.
In stage III gastric cancer, the standard operation is extended cholecystectomy; 44% of patients survive 5 years.
There are supporters of expanding the dissection of lymph nodes (including retropancreatic and aortocaval), but in addition to cholecystectomy, pancreaticoduodenectomy should be performed.
In connection with the development of technology for endoscopic removal of the gallbladder for various indications, a new problem of repeated resection in an expanded volume has arisen in the presence of histological detection of evidence of invasion of the serosa or adjacent organs.
Due to the relative rarity of gastric cancer, no randomized trials have been performed to evaluate the role of adjuvant chemotherapy and radiotherapy after surgery. Pilot studies on a small number of patients are known. The poor results in all groups are striking.
Chemotherapy unresectable gastric cancer has little success. Mitomycin is ineffective when administered intravenously. At the same time, with intra-arterial administration of this antibiotic, it was possible to increase the median survival from 5 to 14 months, with an immediate effect recorded in 48% of patients.
Good immediate results were achieved in a series of studies:
- the combination of fluorouracil, leucovorin, hydroxyurea led to a partial effect in 30% of cases, the median duration of the effect was 6.5 months, and the median survival was 8 months;
- the combination of mitomycin and fluorouracil caused an immediate effect in 47% of patients with gastric cancer;
- in a small group of patients with gastric cancer, thanks to the combination of fluorouracil, doxorubicin and carmustine, a very significant effect was achieved (in 42.8% of cases).
Cancer of the papilla of Vater The papilla of Vater is located on the border of the middle and lower thirds of the descending part of the duodenum (on the posteromedial wall). Its height varies, up to a maximum of 2 cm. At the top of the nipple there is an orifice of 2-4 mm, into which the common bile duct and the Wirsung duct open together. Sometimes these ducts open separately. At a distance of 3 cm in one third of cases there is a small duodenal papilla (Santorini).
Carcinoma of the papilla of Vater (PVC) arises from the columnar epithelium of the last centimeter of the common bile duct at the site of passage through the wall of the duodenum. This is the most common variant of RFS.
RFS is considered the most curable tumor of the pancreatobiliary zone. The reason for this is early diagnosis: even very small tumors of the papilla of Vater lead to pancreaticobiliary compression, the expression of which is the rapid onset of jaundice.
Metastases in regional lymph nodes usually appear when the primary tumor is more than 2.5 cm. The main method of treatment for RFS is surgical . The stomach, duodenum, segment of the jejunum, gallbladder, distal part of the common bile duct, head and neck of the pancreas, and regional lymph nodes are resected as a single block.
At stage I, 76% survive 5 years, at stages II and III - 17%.
For small tumors or in somatically unfavorable patients, operations such as ampulla resection are performed. In the cited studies, the average age of patients was 72 years, postoperative mortality was 9%, 43% survived 5 years.
In the 1990s, a technique for endoscopic removal of RFU was developed. Of the 25 patients, 6 had relapses of the disease after 7-79 months.
The relapse rate after adjuvant radiation therapy (50 Gy) and fluorouracil infusions in the first 3 days and last 3 days of radiation therapy (500 mg/m2 per day) significantly decreased, life expectancy did not increase.
Due to the rarity of this form of cancer, oncologists do not have much experience with chemotherapy. It is known that mitomycin C is effective in 15% of cases, the combination of fluorouracil, ifosfamide and mitomycin is effective in 25%, and the combination of fluorouracil and cisplatin is effective in 31%.
Conclusions 1. The only radical treatment for cancer of the distal extrahepatic ducts is pancreaticoduodenectomy; radical operations for proximal bile duct cancer are liver resections (lobectomies or removal of several segments); In case of cholangiocellular liver cancer, radical resections are possible only for small tumors.
2. Effective against bile duct cancer in stage IV. are: infusions of fluorouracil and leucovorin (partial effect in 39%), a combination of leucovorin, fluorouracil and carboplatin (effect in 49% of cases), a combination of fluorouracil and gemcitabine (effect in 43% of cases), intra-arterial infusion of fluorouracil and mitomycin (effect in 60% of cases). cases).
3. The optimal operations for gallbladder cancer (T 1 - T 2) are considered to be simple cholecystectomy, for stage III. - extended cholecystectomy (in addition to the gallbladder, the lymph nodes of the hepatoduodenal ligament are removed, resection of the gallbladder bed is performed, if the bile ducts are removed, a hepaticojejunostomy is constructed).
4. Chemotherapy for disseminated gallbladder cancer has little success. Partial remissions can be caused by combinations of fluorouracil, leucovorin and hydroxyurea (in 30%), mitomycin and fluorouracil (in 47%), fluorouracil, doxorubicin and carmustine (in 43% of cases).
5. The main method of treatment for cancer of the papilla of Vater is pancreaticoduodenectomy.
6. Chemotherapy for cancer of the papilla of Vater is not very successful; combinations of fluorouracil, mitomycin and ifosfamide (25%), fluorouracil and cisplatin (31%) are considered effective.
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Vater's papilla cancer is a group of malignant tumors localized in the distal part of the common bile duct, at its confluence with the duodenum. Cancer of the papilla of Vater can be primary (as a result of the development of sarcoma, carcinoid or adenocarcinoma in it (90% of cases of tumor of the papilla of Vater)) and secondary (due to the spread of a duodenal tumor to it).
Cancer of the papilla of Vater - causes
The exact causes of the disease have not been established. Patients with familial polyposis have an increased risk of developing nipple cancer. Mutations in the K-ras gene may influence the likelihood of developing the disease. Every year, about 2 thousand new cases of carcinoma of the papilla of Vater are registered in the world, accounting for 0.2% of all malignant tumors of the gastrointestinal tract.
Cancer of the papilla of Vater - symptoms
The main clinical manifestations of Vater's papilla cancer:
- obstructive jaundice (in 75% of cases)
- itchy skin
- anorexia
- dyspepsia
- vomit
- weight loss
- dull pain in the epigastric region (in the later stages of the disease they radiate to the back)
- increased body temperature (with concomitant cholangitis)
- Diarrhea occurs when the pancreatic duct is obstructed
- When bleeding occurs from the tumor, blood appears in the stool of patients
Cancer of the papilla of Vater - diagnosis
By diagnosing oncological disease, the papilla of Vater can be differentiated from similar ailments, which are known as biliary stricture, cholelithiasis, cholangiocarcinoma, pancreatic cancer, chronic pancreatitis and non-Hodgkin's lymphoma.
Laboratory diagnostic methods include detailed tests, including tumor markers, bilirubin, etc. An ultrasound examination of the abdominal cavity and a biopsy will more accurately indicate the likelihood of a tumor.
Using spiral CT in the abdominal cavity, the stage of the tumor can be more accurately examined. They can also carry out other testing methods that will undoubtedly help in determining the diagnosis.
Cancer of the papilla of Vater - treatment
Treatment through surgery should be based on an individual therapy plan, which depends on the individual course of the disease and the health status of a particular patient.
If an oncological process is detected beyond the initial location in other organs, then chemotherapy or the use of rays should be prescribed.
As a rule, therapy begins with chemical treatment, and then it is necessary to conduct a control PET-CT to determine the dynamics of the process.
If the initial stage of the nipple of Vater is detected, then almost 80% of patients can live up to five years. Determination of this type of cancer at the second and third stages indicates that five-year survival will be observed in approximately 17% of patients.
The absence of metastases indicates the need for pancreaticoduodenal resection in accordance with the Whipple procedure, which is a radical method. This type of surgical intervention may include removal of the lesser omentum, stomach, duodenum, tissue, the right half of the greater omentum, regional lymph nodes, etc. The presence of multifocal lesions of the pancreas can also be eliminated.
Before deciding to undergo such an operation, you should go through certain diagnostic stages that will help establish an accurate diagnosis or develop an optimal treatment plan.
Cancer of the papilla of Vater - why clinics in Poland? How can Polandmed help you?
If you or a person close to you is faced with the need for accurate diagnosis or high-quality treatment for cancer of the papilla of Vater, professional consultants from Polandmed will take care of organizing affordable treatment in clinics in Poland. In addition to paperwork, selection of accommodation, organization of departure and registration of medical visas, you will be provided with a professional consultant who will optimize the costs of treatment or diagnosis, develop and agree on a treatment, operation or diagnosis plan, and also provide additional services at your request.
Today, clinics in Poland are well-equipped medical centers that offer accurate and comprehensive diagnostics and treatment of diseases at the European level at an affordable cost. Polish doctors obtain very good treatment results especially in such areas as oncology, orthopedics, pediatric and adult cardiac surgery and cardiology, etc.
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Abdominal pain, a feeling of heaviness or bloating, and general poor health are familiar to quite a large number of people, especially those prone to overeating or abusing heavy foods. And most often, an experienced food lover gets rid of these symptoms with enzyme-containing medications. However, if these symptoms are regular or do not depend on the volume and calorie content of food, there is reason to worry and get examined. . . .
Contents Oncology of the large intestine Symptoms of the disease Varieties and stages of the disease Causes of occurrence Diagnosis of the disease Treatment of the disease, effectiveness and average prices Oncology of the large intestine The large intestine is the section of the digestive system that is located at its end. Its length is 1.5-2 meters. The cecum along with the appendix, the ascending and descending colons, the sigmoid and rectum. Colon cancer is a growing tumor. . . .
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Vater's Nipple [papilla duodeni major(PNA); named after the German anatomist Vater (A. Vater, 1684-1751); synonym: major duodenal papilla, major duodenal papilla, papilla vateri] - an elevation on the inner surface of the wall of the duodenum, corresponding to the junction of the common bile duct and the pancreatic duct into the duodenum.
Vater first described this formation in 1720. The width of Vater's nipple is about 4 mm, height up to 7 mm; most often it is located approximately in the middle of the descending part of the duodenum (see). Its origin is associated with the passage of the common bile duct (ductus choledoehus) and the pancreatic duct, or Wirsung's duct (ductus pancreaticus, s. ductus wirsungi) in this section of the intestinal wall. The common bile duct lifts its mucous membrane in the form of a longitudinal fold, at the base of which the papilla of Vater is formed (Fig.) Most often, in the area of the papilla of Vater, the common bile duct expands, forming the hepatopancreatic ampulla (ampulla hepatopancreatica), into which the pancreatic duct flows (see .), and both ducts open on the nipple of Vater with one common opening. There are other options for the flow of these ducts into the duodenum (see Bile ducts). In the circumference of the hepatopancreatic ampulla, in the thickness of the papilla of Vater, there are ring oblique and longitudinal muscle bundles that intertwine with each other and form the sphincter of the hepatopancreatic ampulla, or the sphincter of Oddi (sphincter ampullae liepatopancreaticae, s. sphincter Oddi), functioning independently of the duodenal muscles intestines. The common bile duct and the pancreatic duct at their confluence have independent sphincters (sphincter ductus choledochi, sphincter ductus pancreatici).
The blood supply to the papilla of Vater is carried out by the ventral and dorsal branches of the retroduodenal arteries (aa. retrod uodenales). Venous outflow of blood occurs through the anterior and posterior pancreaticoduodenal veins (vv. pancreaticoduo-denales), flowing into the superior mesenteric vein (v. mesenterica sup.). Lymphatic vessels are connected with the lymphatic vessels of the terminal part of the common bile duct, duodenum and head of the pancreas and communicate with the lymph nodes of the root of the mesentery of the colon. The vagus nerve and sympathetic fibers of the celiac plexus (plexus celiacus) are involved in the innervation of the nipple of Vater.
The nipple of Vater, in particular the sphincter of the hepatopancreatic ampulla, as well as the sphincters of the common bile duct and pancreatic duct play a major role in regulating the flow of bile (see) and pancreatic juice into the duodenum and preventing duodenobiliary and duodenopancreatic reflux (see). When these sphincters relax, bile and pancreatic juice enter the duodenum; when they contract, their flow into the intestine stops, and the bile is directed through the cystic duct into the gallbladder (see). Secretory pressure of the liver (see), motility of the gallbladder, tone of the walls of the bile ducts, peristalsis of the duodenum, etc. also play a role in the mechanism of movement of bile into the duodenum.
Methods for studying the papilla of Vater include: duodenal intubation (see), duodenography (see, Relaxation duodenography), duodenoscopy (see), endoscopic retrograde cholangiopancreatography (see, Retrograde pancreatocholangiography), cholangiography (see), intravenous choleography (see. ), choledochomanometry, choledochoscopy (see), ultrasound examination of the bile ducts and pancreas (see Ultrasound diagnostics), computed tomography (see Computer tomography).
Diseases of the Vater's nipple are clinically manifested by stenosis syndrome (see Stricture). According to V.V. Vinogradov (1962), stenosis of the papilla of Vater was observed in approximately 26% of patients who underwent surgery on the bile ducts for non-tumor diseases.
The causes of Vater's nipple stenosis are varied. In some cases, stenosis of the nipple of Vater is congenital. Some researchers point to the possibility of stenosis of the Vater's nipple, caused by functional disorders such as dyskinesia (see), in which there is a prolonged spasm of the sphincter of the hepatopancreatic ampulla, alternating with its atony. These disorders are usually combined with similar disorders of the bile ducts and gallbladder and can also be observed in diseases of the stomach (see), pancreas, and duodenum. Most often, Vater's nipple stenosis occurs with cholelithiasis (see) due to the frequent passage of sand and small stones, as well as with duodenitis (see), cholangitis (see), pancreatitis (see), as a result of Vater's inflammation that occurs with these diseases nipple - acute or chronic papillitis.
Morphologically, in the initial stage of stenosis of the papilla of Vater, swelling and leukocyte infiltration of its walls are observed. Later, an atrophic or hypertrophic process is found in the mucous membrane of the hepatopancreatic ampulla, often with hyperplasia of the glandular apparatus and the formation of adenomatous growths.
In the muscular apparatus of the sphincter of the ampulla, connective tissue develops, sclerotic and cicatricial changes occur, leading to a narrowing of the nipple of Vater. Sometimes these changes spread to the excretory sections of the common bile duct and pancreatic duct.
The clinical picture of Vater's nipple stenosis consists of symptoms of biliary hypertension, and in the most severe cases - cholangioedema and obstructive jaundice (see), and these phenomena are often temporary, and jaundice is remitting. Pain in the right hypochondrium is observed in the vast majority of patients. In approximately 30-40% of patients, stenosis of the papilla of Vater is accompanied by a picture of recurrent pancreatitis associated with congestion in the pancreas caused by blockage of the pancreatic ducts. The severity of the wedge, manifestations depends on the degree of stenosis of the Vater's nipple, which can be compensated, subcompensated and decompensated.
Diagnosis of Vater's nipple stenosis is difficult, since its main clinical symptoms are not specific; they are also observed in gallstone disease, cholangitis, duodenitis, pancreatitis and other diseases with which stenosis of the papilla of Vater is often combined. The diagnosis of Vater's papilla stenosis can sometimes be clarified by multi-stage duodenal intubation, intravenous cholegraphy, and duodenoscopy using fiber optics. The most effective way to diagnose stenosis of the papilla of Vater is to examine the common bile duct during surgery (probing, cholangiomanometry, cholangiography, choledochoscopy).
Treatment of functional stenosis of the nipple of Vater is conservative (antispasmodic and antihistamines, choleretic agents, and, if indicated, antibiotics and sulfonamides). Surgical treatment of organic stenosis of the nipple of Vater. In case of isolated stenosis of the papilla of Vater and the absence of inflammatory phenomena in it and the wall of the duodenum, operations are performed on the papilla of Vater - bougie, transduodenal papillotomy (dissection of the mucous membrane of the papilla of Vater), transduodenal papillosphincterotomy (dissection of the mucous membrane of the papilla of Vater and the sphincter of the hepatic-pancreatic ampulla) and papillosphincteroplasty (suturing after papillosphincterotomy of the edges of the dissected mucous membrane of the duodenum and hepatic-pancreatic ampulla); A less traumatic method of endoscopic papillosphincterotomy has become widespread - dissection of the sphincter with a special instrument - a papillotome inserted through the biopsy channel of the endoscope (see Endoscopy). When stenosing scar-sclerotic changes spread to the common bile duct, the presence of stenosing pancreatitis (blocking the flow of bile as it passes through the head of the pancreas) and inflammatory phenomena in the wall of the papilla of Vater and the duodenum, choledochotomy (see), choledochostomy (see. ) or bypass biliary anastomoses are applied (see Choledochoduodenostomy, Cholecystoenterostomy).
In some cases, papillosphincterotomy and supraduodenal choledochoduodenostomy are indicated. For example, when Vater's nipple stenosis is combined with stenosing pancreatitis, bypass choledochoduodeno-anastomosis eliminates obstruction of the common bile duct, and papillosphincterotomy restores the patency of the pancreatic duct.
The prognosis for isolated stenosis of the nipple of Vater in cases of restoration of bile outflow is favorable. When Vater's nipple stenosis is combined with other diseases, the prognosis depends on the nature of these diseases and the operations used.
Neoplasms of the papilla of Vater include benign and malignant (cancerous) tumors that arise in the mucous membrane of the duodenum covering the papilla of Vater, the hepatopancreatic ampulla and the mouth of the common bile duct or pancreatic duct.
Benign tumors of the papilla of Vater are quite rare. More often these are papillomas (see Papilloma, papillomatosis) or adenomas (see Adenoma), which form the hepatopancreatic ampulla and prolapse into the lumen of the duodenum. The tumor sizes range from a few millimeters to 3-4 cm in diameter. Most often, tumors consist of mature epithelial cells and have a glandular structure; Often they exhibit pronounced inflammation.
The main clinical manifestations of benign tumors of the nipple of Vater are associated with its obstruction (pain in the right hypochondrium, intermittent jaundice, symptoms of recurrent pancreatitis). Sometimes blood is found in the duodenal contents. The most effective diagnostic method is visual examination of the papilla of Vater during fibroduodenoscopy, during which a tumor biopsy can be performed (see Biopsy). Treatment of benign tumors of the Vater's nipple is surgical (papillectomy). The prognosis for timely removal of the tumor is favorable. In some cases, malignancy of the tumor is possible.
Cancer of the papilla of Vater (see Cancer), according to various researchers, occurs in approximately 5 - 10% of patients with malignant neoplasms of the hepatobiliary and pancreaticoduodenal zones.
Macroscopically, the cancerous tumor of the Vater's nipple looks like a solitary node, polyp or ulcer. The solitary node causes prolapse of the nipple of Vater and a gaping of its mouth, through which bleeding tumor masses are visible. Polypous forms resemble cauliflower. A cancerous ulcer is usually irregular in shape with dense, undermined edges, a bleeding bottom and purulent overlays. Sometimes the tumor infiltrates neighboring tissues, spreading to the duodenum, common bile duct and pancreas. Microscopically, adenocarcinoma is most often detected with a picture of solid or mucinous cancer. Cancer of the Vater's nipple is characterized by relatively slow growth, but obstruction of the Vater's nipple develops already at the beginning of the disease. Metastasis occurs to regional lymph nodes, and later to distant organs.
The disease usually occurs in middle and old age, more often in men. Sometimes at the onset of the disease, patients experience pain resembling biliary colic, weakness, general malaise, and increased body temperature. However, more often the early symptom of the disease is jaundice, which is often permanent, followed by dyspeptic symptoms (anorexia, nausea, feeling of heaviness in the epigastric region), weakness, weight loss; sometimes, due to concomitant cholangitis, body temperature rises. During a clinical examination of the patient, an enlarged liver is determined and an enlarged, painless gallbladder is palpated (Courvoisier's symptom). Data from laboratory clinical studies (blood, urine, feces, etc.) indicate the presence of obstructive jaundice; blood and atypical cancer cells can be found in the duodenal contents.
The diagnosis of Vater's nipple cancer is made on the basis of clinical examination of the patient and results obtained using instrumental research methods (see above). Significant assistance is provided by x-ray examination of the duodenum and bile ducts. The most effective method for diagnosing cancer of the papilla of Vater is fibroduodenoscopy, in which you can directly see changes in the papilla of Vater and perform a biopsy of the tumor.
Treatment for Vater's nipple cancer is only surgical. For localized tumors, transduodenal excision of the papilla of Vater (papillectomy) is performed. In cases of tumor invasion of the duodenal wall or its spread to the pancreatic duct and common bile duct, pancreaticoduodenectomy (removal of the head of the pancreas and duodenum) or total pancreaticoduodenectomy (see). If it is impossible to remove the tumor or there are distant metastases, bypass biliary anastomoses are performed.
The prognosis for cancer of the Vater's nipple depends on the timeliness of the radical operation and the nature of the operation. According to many surgeons, radical surgery for cancer of the Vater's nipple is possible in 50-70% of patients; it often gives encouraging results.
Bibliography: Aripov U. A. et al. Operations on the large duodenal nipple and pancreas, Tashkent, 1978; Balalykin A. S., Kornilov Yu. M. and Revyakin V. I. Endoscopic sphincterotomy of the ampulla of the papilla of Vater for obstructive jaundice, Sov. med., no. 11, p. 45, 1979; In ii n o-gradov V.V. Diseases of the Vater's nipple, M., 1962, bibliogr.; G r i sh k e-v i h E. V. Clinic, diagnosis and surgical treatment of stenosis of the papilla of Vater, Klin, hir., No. 7, p. 12, 1965; N i-d e r l e B. et al. Surgery of the biliary tract, trans. from Czech, Prague, 1982; S a-v e l e v V. S., Buyanov V. M. and B a l a l y k i n A. S. Endoscopy of the abdominal organs, M., 1977; Shkrob O. S., Lopata Yu. M. and Safronov V. V. Diagnostic value of special research methods for obstructive jaundice, Surgery, No. 9, p. 48, 1973; Fodisch H. J. Feingewebliche Studien zur Orthologie und. Pathologie der Papilla Vateri, Stuttgart, 1972; Mattig H. Papilla Vateri, Lpz., 1977; The papilla vateri and its diseases, ed. by M. Classen a. o., Baden-Baden a. o., 1979.
D. F. Blagovidov, A. S. Yakovlev.
A 42-year-old patient, an economist by profession, was admitted to us with complaints of jaundice, severe itching of the skin, weakness and emaciation. Ill for over two and a half months. The disease began unnoticed: jaundice appeared, which the patient was told about by those around him.
Since then, the jaundice progressed, then other phenomena appeared. The temperature is normal all the time. At first, despite the jaundice, he continued to work, but his weakness increased significantly; I had to leave my job. The feces are discolored, gray in color, the urine is deep yellow. The patient does not drink or smoke. During his illness he became noticeably thin. Before this disease I was always healthy.
A 42-year-old man, quite healthy and in good condition, was unexpectedly noticed by those around him that he had jaundice. This circumstance is important evidence that the patient did not feel any subjective disorders.
But once jaundice appears, it relatively quickly reaches great intensity and persists to this day. And only some time after its appearance, the patient began to feel weakness, itching all over his body, and, in the end, was forced to quit work.
From the whole story, we are interested in one of the main symptoms so far - jaundice. We have already examined the question of the origin of various types of jaundice and now we can only say that discolored stool indicates a complete blockage in the places where bile exits.
“Hospital therapy”, A.S. Voronov
Where is this tumor located? It should be looked for where compression of the duct causes complete blockage of the secretion of bile, that is, at the point where the common bile duct flows into the duodenum, most likely in the papilla of Vater, or in the head of the pancreas, where it compresses the bile duct. On the other hand, the same picture of jaundice in rare cases can...
Liver function tests: Takata-Ara – (N – negative); Quick's test - 65% (N - 70-80%). There is a lot of bilirubin in the urine, since a wide, clear green ring is visible at the border of urine with one percent iodine. There is no urobilin in the urine. There is no stercobilin in feces during the sublimate reaction. Blood: red blood cells - 3,400,000, hemoglobin - 1-70 units, color indicator...
The differential sign that distinguishes cancer of the papilla of Vater from the head of the pancreas should be considered intermittent jaundice in the first case and constant in cancer arising from the head of the pancreas. Vater's nipple has a very small diameter, and a slight disintegration of the tumor can already contribute to the passage of bile. To establish a diagnosis of cancer of the papilla of Vater or the head of the pancreas, great importance is attached to the clinic...
Despite the fact that there is a lot of evidence in favor of cancer, the idea of syphilis cannot be completely rejected. Therefore, a trial of antisyphilitic treatment should be performed first. The patient was prescribed Biet's medicine. Using it for two weeks did not give any effect. This finally convinced us that the diagnosis was correct. But since there is no 100% evidence in favor of the tumor,...
But another patient, an employee, 32 years old. Got sick on August 11th. The temperature rose to 37.8°, general malaise, nausea, belching, constipation, poor appetite. The first days I continued to work. Until August 23, the temperature rose; on August 23rd it became normal. At that time he noted jaundice, which was rapidly increasing in intensity. After about a week, the stool became discolored. During the study at this time, there was a general...
An examination at the end of the second month from the onset of the disease revealed a noticeably enlarged, smooth, somewhat compacted liver, protruding four transverse fingers from the hypochondrium. But what is especially important is a large, smooth, elastic formation found in the area of the right lobe of the liver, slightly painful when pressed and movable when breathing. This formation is directly related to the palpable liver. The whole characteristic of this body...
The postoperative period is smooth. The patient began to recover quite quickly: the jaundice disappeared, the liver shrank, the distended gallbladder was no longer palpable: the vomiting stopped; appetite appeared. The temperature is normal all the time. After a year and a half, having gained 15 kg in weight during this time, the patient began to work. As if there were every reason to reject the proposed diagnosis of a tumor and consider...
The radiologist's diagnosis: “duodenal diverticulum.” Numerous radiographs of the stomach and duodenum led another radiologist to the belief that the pattern of changes in the duodenum did not resemble a diverticulum, but rather corresponded to a cicatricial narrowing due to a former ulcer. The changes detected during fluoroscopy and the conclusions of the radiologists could not in any way satisfy the clinician, who was looking for an explanation for what was observed in the patient...
At the time of departure, at the station, the patient suffered from profuse intestinal bleeding, for which he was again sent to the hospital. But even after repeated bleeding, the doctors’ judgment did not change - the patient was sent to Essentuki. It must be pointed out that, from the point of view of the doctors’ latest conclusion, it was impossible to explain the total jaundice at the beginning of the suffering with blockage of the bile duct...
10.IX X-ray of the stomach revealed chronic gastritis. When examining the abdomen, a small amount of free fluid was detected. Due to the fact that vomiting became almost uncontrollable and the patient’s condition deteriorated very quickly, repeated surgical intervention was proposed. A few days before surgery, X-ray examination revealed a “duodenal tumor.” The patient was operated on. An autopsy of the abdomen revealed a large number of dense lymph nodes, mesenteric...
