A woman's nipples are two areoles with natural dense formations protruding above them. Their color may vary depending on the amount of melanin pigment contained in the skin of its owner. So, for red-haired women, the nipples are almost colorless or slightly pink, - pinkish, for brown-haired women - light brown, and for brunettes - dark brown. They can be tiny or huge, depending on the size of the bust, although it is not always 100% accurate.

The shape of the nipples can be elliptical, long, thick and inverse bulges. Elliptical nipples have an oblong elongated shape with an axis of symmetry slightly deviated from the straight vertical. In the case of a reverse bulge, they form a small depression and do not protrude above the breast surface. The category of long includes nipples, the size of which in the vertical projection is very large even at rest. And finally, thick - they are very massive and have an extremely wide horizontal radius both in a state of excitement and at rest.

Non-standard nipples

There are several species that differ in their unusual shape. These include the convex nipple areola, which protrudes noticeably above the skin of the chest and is caused by the reduced state of the muscles of this zone, as well as an increased volume of subcutaneous tissue. In a state of arousal, nipples with a bulging areola usually lose this shape. Also included in this category are those whose diameter is significantly larger than the diameter of a regular pencil.

The constant pointedness of the female nipple, however, like its flat, relaxed state, is an absolute physiological norm.

Another non-standard type is a very large, clear cylindrical shape that gives the impression of great hardness. These are often compared to a bench drill or glass cutting tool. Their complete opposite is the large, wide nipples, which in structure resemble a soft substance that evokes the association with chewing gum.

- malignant tumor of the papilla of Vater, located in the duodenum. Characterized by slow growth and late metastasis with the early onset of obstructive jaundice. Pains, periodic increase in body temperature, enlargement of the liver and gallbladder are observed. In the later stages, bleeding is possible. The diagnosis is made taking into account the symptoms, radiographic data, fibrogastroduodenoscopy and biopsy results. Surgical treatment: gastropancreatoduodenal resection, papillectomy, duodenectomy, palliative interventions.

General information

Cancer of the large duodenal papilla is a malignant neoplasia of the large duodenal (Vater) papilla, localized in the descending part of the duodenum and representing the fistula of the main pancreatic duct and the common bile duct. It accounts for 40% of the total number of oncological lesions of the pyloroduodenal zone, 5% of the total number of gastrointestinal neoplasias and 1-2% of the total number of cancers of various localizations. Cancer of the major duodenal papilla is the third most common cause of obstructive jaundice. Usually affects elderly patients, the average age of patients is 54 years. It is very rare in children. Women suffer less often than men. Treatment is carried out by specialists in the field of oncology, gastroenterology and abdominal surgery.

Causes of cancer of the Vater papilla

The causes of the tumor are not exactly clear. Experts note that a hereditary predisposition is of some importance - the disease is often diagnosed in families whose members suffer from familial polyposis. In addition, some patients have a K-ras genetic mutation. It has been established that neoplasia can develop as a result of malignancy of the adenoma of the nipple of Vater. The list of risk factors also includes chronic pancreatitis and diseases of the hepatobiliary system.

The source of cancer of the large duodenal papilla is the transformed cells of the epithelium of the duodenal mucosa, pancreatic duct or common bile duct. The neoplasm is characterized by slow exophytic growth. In appearance, neoplasia resembles papilloma, a mushroom-shaped growth or in the form of a cauliflower inflorescence. Endophytic forms are less common. In exophytic forms of cancer of the large duodenal papilla, jaundice is often remitting, in endophytic forms it is constant. The diameter of the node during its surgical removal is on average 3 mm.

Microscopic examination reveals cell clusters and separately lying endocrine cells of a fusiform, triangular and cylindrical shape. The number of endocrine cells decreases as the level of differentiation of neoplasia decreases. Usually, cancer of the large duodenal papilla grows into the common bile duct, it is also possible to damage the pancreas and the duodenal wall, lymphogenous and distant metastasis. Lymphogenous metastases are found in 21-51% of patients. Distant secondary foci are rarely detected. Usually the liver is affected, less often the bones, brain, lungs and adrenal glands.

Cancer of the large duodenal papilla can completely obstruct the lumen of the bile duct, less often stenosis is detected. Even with partial compression, due to swelling of the mucous membrane, gross disorders of the outflow of bile occur, which cause the development of obstructive jaundice. Biliary hypertension appears, accompanied by dilatation of the biliary tract and pancreatic ducts. Intestinal obstruction is very rare. With the spread of the process, germination of the intestinal wall and the collapse of neoplasia with the development of internal bleeding are possible.

Vater papilla cancer symptoms

The first manifestation of the disease is often obstructive jaundice, which has arisen against the background of somatic well-being. At first, jaundice is usually intermittent, the normalization of blood biochemical parameters is due to a decrease in edema in the area of \u200b\u200bthe stenotic bile duct. With the progression of cancer of the large duodenal papilla, jaundice becomes more persistent, a change in skin color is detected after intense pain, accompanied by chills and torrential sweats. Patients complain of severe itching. The intermittent nature of jaundice in the later stages (detected in 51% of cases) is due to the collapse of cancer of the large duodenal papilla, accompanied by a temporary restoration of the patency of the bile duct.

On palpation, hepatomegaly is determined. In 60% of patients, an enlarged gallbladder is felt under the lower edge of the liver (Courvoisier symptom). With prolonged obstruction of the biliary tract, cirrhosis of the liver and chronic pancreatitis occur. With the invasion of cancer of the large duodenal papilla into the intestinal wall and the subsequent disintegration of the tumor, bleeding (acute massive or repeated minor) is possible with the development of anemia. With regional metastasis, a change in pain syndrome is noted.

Early weight loss is a characteristic feature of cancer of the major duodenal papilla. The reason for losing weight is stenosis or obstruction of the pancreatic ducts, due to which the enzymes necessary for the breakdown of proteins and fats cease to enter the digestive tract. Violation of the patency of the common bile duct further aggravates the disorders of fat absorption and impairs the absorption of vitamins. Weight loss and vitamin deficiency cause adynamia.

Patients with cancer of the greater duodenal papilla often have diarrhea, accompanied by bloating and abdominal pain. The feces are offensive, clay-gray. In advanced cases, fatty feces can be detected. When regional metastases appear, a change in the nature of the pain syndrome is noted. In the later stages, exhaustion and disorders of the functions of organs affected by distant metastases are determined.

Diagnosis of cancer of the Vater papilla

The diagnosis is fraught with significant difficulties due to the nonspecificity of symptoms. In the process of diagnosis, the oncologist is guided by complaints, physical examination data, radiography, transhepatic or intravenous cholangiography, duodenal intubation, fibrogastroduodenoscopy and other studies. With jaundice, a high level of bilirubin is determined with a predominance of the direct fraction, stercobilin is absent in the feces. In the later stages of cancer of the large duodenal papilla, anemia is detected.

A fairly reliable study is duodenal intubation, during which it is often possible to detect blood in the duodenal contents. Sometimes in the course of this study, cells of neoplasia and pancreatic enzymes are detected. Radiographic signs of cancer of the large duodenal papilla are uneven contours or a filling defect in the area of \u200b\u200bthe inner wall of the duodenum, as well as the lack of patency or deformation of the bile duct in the area close to the nipple of Vater.

When performing fibrogastroduodenoscopy, a tumor-like formation is detected and an endoscopic biopsy of a suspicious area is performed. In some cases, the diagnosis of cancer of the large duodenal papilla cannot be established using standard techniques; to clarify the nature of the pathology, it is necessary to perform a laparotomy, dissect the nipple veins, carry out tissue sampling, and then decide on the scope of the operation based on the data of an urgent histological examination. Differential diagnosis is made with hepatitis, cancer of the head of the pancreas, and cancer of the biliary tract.

Vater papilla cancer treatment

The main method of treating this pathology is surgery, which, depending on the extent of the process, can be radical or palliative. The group of palliative operations includes about ten different variants of anastomoses, allowing to restore the outflow of bile into the digestive tract or (less often) to prevent compression of the duodenum by growing cancer of the large duodenal papilla.

Radical surgery is a difficult and complex intervention, therefore, it is performed only after careful selection of patients in accordance with standards, including the permissible degree of depletion, the level of proteins in the blood, certain indicators of pulse and vital capacity of the lungs, etc. Patients with cancer of the large duodenal papilla are performed gastropancreatoduodenal resection. If there are contraindications to radical intervention, conditionally radical operations are performed: papillectomy, duodenectomy, or economical pancreatoduodenal resection. Radiotherapy and chemotherapy for cancer of the large duodenal papilla are ineffective.

Large duodenal (vater) papilla Is an anatomical formation that is located in the intestinal cavity. A duct from the bile duct opens into it, through which bile acids and digestive enzymes of the pancreas enter the duodenum.

Vater papilla is located in the wall of the duodenum, in its descending part. The average distance between the pylorus of the stomach and the duodenal papilla is 13-14 cm. It is located next to the longitudinal fold on the organ wall.

Externally, the papilla of the Vaters is a small elevation ranging in size from 3 mm to 1.5-2 cm. The shape of the formation is variable, it may look like a hemisphere, a flattened platform or a cone. In the area of \u200b\u200bthe large duodenal papilla, the common bile duct ends, which is combined with the pancreatic duct. In some cases (about 20% of patients), these ducts open into the duodenum with separate holes. Such anatomical variation is not considered a sign of pathology, but a variant of the norm, since the separate flows do not affect the activity of digestion in any way.

Vater's nipple forms a hepato-pancreas ampulla, in which the secretions of the glands accumulate. The flow of juice from the ducts is controlled using. It is a circular muscle that can regulate the lumen of the duodenal papilla according to the stages of digestion. If it is necessary for the secretion to enter the intestine, the sphincter relaxes, and the papilla cavity expands. During the rest period, when a person does not digest food, the circular muscle contracts and contracts tightly, which prevents the release of digestive enzymes and bile into the intestines.

Functions

• separation of the biliary system from the intestines;
• control of the flow of enzymes into the duodenum;
• prevention of the throwing of food masses into the biliary system.

Diseases of the large duodenal papilla

Cancer

- This is a malignant neoplasm in the tissue of the papilla, which occurs primarily or develops with metastasis from other organs. The tumor is characterized by a relatively slow growth. Initially, symptoms of the disease may not appear. Later, signs of obstructive jaundice are added, arising from the overlap of the bile ducts by the tumor.

The clinical picture of the disease includes:

• yellowing of the skin and sclera;
• chills, increased sweating;
• diarrhea, change in the nature of feces (fetid feces with droplets of fat);
• pain in the upper abdomen on the right;
• itchy skin;
• increased body temperature.

The prognosis for the patient's life is relatively poor. With a prolonged course of the disease, severe complications may occur. Cancer of the papilla can cause intestinal bleeding, circulatory disorders, cachexia. The pathological process can spread to other organs, which leads to the appearance of metastases.

Stenosis

Stenosis of the large duodenal papilla is a pathology characterized by a narrowing of the lumen of the papilla and a violation of the outflow of secretions of the pancreas and gallbladder. Stenosis of the papilla is often confused with gallstone disease, since the mechanism of development of these conditions is very similar. Both conditions have the following symptoms:

• sharp, sudden pain in the right side of the abdomen;
• yellowness of the skin and mucous membranes;
• fever;
• excessive sweating.

Unlike cholelithiasis, stenosis of the Vater papilla never leads to a complete cessation of the flow of bile and enzymes, therefore, periods of severe jaundice in this pathology alternate with intervals of complete remission.

Dyskinesia

Dyskinesia of the large duodenal papilla is a functional disorder that occurs due to a violation of the nervous regulation of the contractions of the sphincter of Oddi. This condition has two main forms:

1. Atony of Vater's papilla leads to the fact that the regulation of bile secretion is disrupted, it enters the duodenum uncontrollably even outside the digestive process.
2. The second form is characterized by hyperfunction of the sphincter of Oddi, which leads to a narrowing of the lumen of the papilla and a slow release of secretions into the intestines.

The clinical picture of the disease is characterized by the following symptoms:

• acute pain in the upper abdomen on the right, which radiates to the scapula;
• connection of unpleasant sensations with food intake;
• the occurrence of night pains;
• Nausea and vomiting.

The disease has a chronic course. The diagnosis of dysfunction of the large duodenal papilla is made only if the symptoms of the pathology persist for at least 3 months. Pathology requires complex treatment, which, in addition to medications, includes psychotherapy to correct disorders of the nervous system.

Methods for diagnosing the state of the anatomical structure

Diseases of the digestive system are quite common pathologies that occur in the vast majority of the world's inhabitants. However, not everyone knows that many diseases of the gastrointestinal tract arise as a result of pathological conditions of the large duodenal papilla. From the materials of our article, the reader will learn about what BDS is, what types of diseases of this structure are known to medicine, how pathological conditions are diagnosed and what kind of therapy is carried out in this case.

BDS concept

The large duodenal papilla (BDS) is an anatomical structure of a hemispherical shape, which is located on the mucous membrane of the descending part of the duodenum. In the medical literature, OBD can be found under other names - the large papilla of the duodenum, or the papilla of Vater. And yet, what is BDS? It is a structure ranging in size from 2 mm to 2 cm, which performs a very important function - it connects the common bile duct, the main pancreatic duct and the duodenum. BDS regulates the flow of bile and pancreatic juice into the small intestine and prevents intestinal contents from entering the ducts.

In the structure of the OBD, pathological changes can occur under the influence of various factors - a variety of pathogenic microflora, pressure fluctuations and changes in acid-base balance, stagnation in the cavity, etc. In addition, the structure of the organ can be disturbed by the migration of stones or other dense structures along the bile duct.

OBD pathologies

Diseases of the large duodenal papilla are very diverse. With the development of modern diagnostic methods, conclusions about functional disorders in this structure are encountered much more often than previously thought. However, due to untimely and rather difficult diagnostics, medical practice often encounters a huge number of unsatisfactory results in the treatment of patients with cholelithiasis or pancreatitis, which developed against the background of disorders in the structure of the OBD.

Tumor-like neoplasms are considered to be a common pathology of OBD - hyperplastic polyps account for up to 87% of benign neoplasms. Polyps usually do not degenerate into malignant tissue. Adenomas are a more rare disease; OBD cancer accounts for up to 25% of all malignant neoplasms. OBD stenosis is diagnosed in 4-40% of patients. As a rule, OBD pathologies are interconnected with which occurs in every tenth inhabitant.

Classification of diseases OBD

Diseases of the large duodenal papilla are classified into two large groups:

• primary,
• secondary.

Primary diseases include those disorders that occur and are localized within the structure of the OBD - papillitis (inflammatory disease); spastic stenosis of the OBD, which can later transform into papillosclerosis; age-related changes in the OBD; congenital anomalies; benign and malignant neoplasms - lipomas, melanomas, fibromas, adenomas, polyps, papillomas.

Secondary diseases of OBD are stenoses caused by gallstone directly related to the cause that caused it. So, if the pathological process is a consequence of a disease of the biliary system, the course of the disease will be similar to signs of cholelithiasis - a pathology characterized by the formation of stones in the gallbladder or bile ducts, accompanied by a feeling of heaviness in the hypochondrium, flatulence, heartburn, unstable stools.

There is a concept of combined stenosis - a violation of the OBD function, which arose against the background of a duodenal ulcer. In this case, there is a lack of OBD.

Pancreatitis

If pathological processes in the structure of OBD are caused by inflammation of the pancreas, the manifestations of the disease will be similar to those of pancreatitis.

Pancreatitis is an inflammatory process in the pancreas. It is noteworthy that the picture of the course of the disease can be different - the pathology can develop rapidly, taking an acute form, or not manifest itself for a long time, which is typical for the chronic form of the course.

The main symptom of acute pancreatitis is a very severe cutting pain in the upper abdomen - right or left hypochondrium. The pain can be shingles and does not stop even after taking antispasmodics or analgesics. This is what BDS is and what are the consequences of the violation of its functions.

In addition to pain with pancreatitis, muscle weakness and dizziness occur. The main signs of pancreatitis on ultrasound are changes in the shape and unevenness of the edges of the pancreas. When diagnosed, cysts can be found in the organ. I must say that the disease is difficult. And if untimely intervention, it can be fatal.

Spastic stenosis BDS

BDS stenosis is a pathology with a benign course, which is caused by obstruction of the bile and pancreatic ducts due to inflammatory changes and cicatricial narrowing of the papilla. How is it going? The passage of the stone causes injury to the papilla, and an active infectious process in the folds leads to the development of fibrous tissue and stenosis of the areas of the BDS ampulla.

As you know, the structure of OBD is directly influenced by the age of a person. People of advanced age with gallstone disease suffer from an atrophic-sclerotic form of chronic papillitis. The contingent, whose age has not reached the sixty-year milestone, is subject to hyperplastic changes in the OBD (adenomatous, adenomyomatous).

In recent years, due to the fact that endoscopes are used in the diagnosis of OBD diseases, it became possible to clearly distinguish between stenosing and catarrhal (non-stenosing) papillitis. The first form of pathology is associated with gallstone disease. If stones are not formed in the body, then the development of the disease is caused by a chronic infection that spreads with the flow of lymph.

Forms of BDS stenosis

Three forms of stenosis are distinguished depending on morphological signs:

• inflammatory sclerotic stenosis is a pathology characterized by various degrees of fibrosis;
• fibrocystic stenosis - a disorder in which, together with the formation of fibrosis, small cysts are formed - sharply expanded glands due to compression by muscle fibers;
• adenomyomatous stenosis is a pathology in which adenomatous hyperplasia of the glands occurs, as well as hypertrophy of smooth muscle fibers and proliferation of fibrous fibers, a violation very often occurs in the elderly.

In addition, cicatricial stenosis of the OBD is classified:

• on primary,
• secondary.

Primary stenosis does not cause changes in the bile ducts. Pathology is caused by degenerative changes in the papilla itself, which are manifested in atrophy of the muscle layer. Sometimes primary stenosis is a congenital abnormality.

Secondary stenosis is a consequence of already existing changes in the structure due to injury to the papilla due to migration of stones or surgery.

Depending on the extent of the spread of the disease, OBD stenosis is divided:

• on isolated,
• common.

Diagnostics

Today, medicine uses several fairly effective methods for diagnosing OBD diseases. Let's take a closer look at some of them.

Endoscopic ultrasonography is a technique in which the structure of the OBD is examined using an optical device - an endoscope. A photo of the papilla taken during a similar study is shown above.

Transabdominal ultrasonography is a screening method of examination using ultrasound, which allows you to very accurately identify structural changes in the gallbladder, liver, pancreas, and ducts. In addition, the technique determines the homogeneity of the gallbladder cavity and its contractility, the presence / absence of intracavitary inclusions.

The next method for diagnosing pathologies of OBD is ultrasound cholecystography-manipulation, with the help of which motor-evacuation is examined within two hours from the moment of taking a choleretic breakfast.

Dynamic hepatobiliscintigraphy is a procedure based on the assessment of the absorption and excretory function of the liver. Fractional chromatic allows to determine the tone of the gallbladder; colloidal stability of the hepatic fraction of bile and its bacteriological composition. With gastroduodenoscopy, the condition of the OBD is assessed, as well as the observation of the nature of the flow of bile. In addition to these methods, there is computed tomography and laboratory diagnostics.

BDS: treatment

At the heart of the treatment of OBD stenosis is the task of restoring the normal outflow of bile and pancreatic juice into the duodenum. In accordance with this task, there are a number of principles, adherence to which will help to achieve success in treatment:

• psychotherapy, treatment of neuroses, stabilization of hormonal levels, minimization of stress, rest, proper diet;
• treatment of pathologies of the abdominal organs,
• elimination of dyspeptic factors.

In order to eliminate neurotic disorders, sedatives, infusions or decoctions of various herbs are used. In addition, the patient is shown psychotherapy sessions.

An important part of successful treatment is diet:

• fractional food intake;
• refusal from alcohol and carbonated drinks, as well as smoked and fried foods;
• restriction in the intake of egg yolks, muffins, creams, strong coffee and tea;
• frequent consumption of cabbage, wheat bran and buckwheat porridge;
• taking antispasmodics that relieve pain attacks.

BDS stenosis is often treated surgically. Distinguish between corrective and non-corrective operations. The first group includes endoscopic PST, BDS bougienage.

During the period of remission, in addition to the diet, patients are recommended supportive therapy - daily walking, morning exercises, swimming are beneficial.

Summing up the above, we can summarize that many arise against the background of a failure in the work of one small structure. Such violations lead to serious problems in the body and are often amenable to correction only by surgery. That's what BDS is.