Overview
It refers to adenomas containing both tubular and villous structures, most of them are asymptomatic in the colorectum, but a few of them may present with symptoms such as blood in the stool and changes in bowel habits, which are closely related to long-term chronic inflammatory stimulation, intestinal bacterial flora disorders, and heredity. Once the diagnosis is confirmed, it is important to have surgery as soon as possible.
Definition
Tubular villous adenoma refers to benign tumors originating from the mucosal epithelium of the gastrointestinal tract and having both tubular and villous adenomatous tissues.
It is also known as a mixed adenoma and has a higher risk of becoming cancerous.
Tubular villous adenomas are most common in the rectum and sigmoid colon, and this article focuses on colorectal tubular villous adenomas.
Pathogenesis
There is little information on tubular villous adenoma in the literature, and the following is the incidence of colorectal tubular villous adenoma.
Tubular choriocapillary adenomas account for 5% to 10% of colorectal adenomas.
The prevalence is higher in men than in women.
The prevalence is low in people under 40 years of age and higher over 60 years of age.
Causes
Causes
Tubular choriocapillaris adenoma is a subtype of adenoma. The etiology and pathogenesis are unknown and may be related to the following factors.
Dietary habits
Long-term high-fat, low-fiber diet, high fat intake will affect the production of bile acids and fatty acids, which in turn causes excessive proliferation of epithelial tissues and cells, and ultimately induces tubular choriocapillaris adenoma [1].
Long-term overeating aggravates the burden on the intestinal tract, impairs intestinal function, and increases the risk of intestinal cell proliferation, which in turn causes tubular villous adenoma.
Intestinal flora disorders
Disorders of intestinal flora lead to long-term chronic inflammation.
The inflammatory markers (C-reactive protein, reactive oxygen species, plasma fibrinogen, etc.), can inhibit apoptosis and promote cell proliferation, angiogenesis and metastasis, which in turn cause adenomas.
It is common in people with intestinal diseases, non-alcoholic fatty liver disease, overweight or obesity [3].
Genetic factors
People with a family history of adenoma have a significantly higher risk of developing the disease.
Long-term chronic inflammatory stimulation
Long-term constipation, etc. can cause repeated stimulation of the intestinal mucosa by stool, causing chronic inflammation, and long-term episodes may cause tubular villous adenoma.
Overweight or obesity
The proportion of visceral adipose tissue increases in overweight or obese patients, leading to the release of inflammatory factors such as C-reactive protein, which in turn induces adenoma.
Metabolic abnormalities
Total cholesterol, triglycerides, uric acid, and dyslipidemia are all risk factors for the development of adenomas.
Smoking and alcohol consumption
Alcohol consumption is a risk factor for adenomas, and long-term smokers have a three- to four-fold increase in prevalence over nonsmokers [3].
Staying up late
Staying up late disrupts the body’s circadian rhythm and affects apoptosis in the body, which in turn increases the risk of the disease.
Risk factors
The following factors increase the risk of developing tubular villous adenoma and are high risk factors for the disease.
A family history of adenomas and malignant tumors of the digestive tract.
Having non-alcoholic fatty liver disease, chronic viral hepatitis, liver transplantation.
Have inflammatory bowel disease, Barrett’s esophagus, Helicobacter pylori infection, gastric polyps, colorectal melioidosis, schistosomal enteropathy.
Have acromegaly, diabetes, overweight or obesity.
Chronic diarrhea, constipation.
Long-term late night, smoking, drinking.
Have bad dietary habits: high fat, high animal protein, high sugar diet, chewing betel nut.
Intake of high sugar and sugary drinks during adolescence.
Symptoms
Most of the tubular villous adenomas have no obvious symptoms. If symptoms occur, they often vary depending on the size, number and location of the adenomas.
Main symptoms
Blood in the stool
Blood in stool is the most common symptom.
There is often intermittent blood in the stool, which is bright red in color and may be mixed with mucus.
Most of the feces are bloody, a few can not be seen with the naked eye, but the fecal occult blood test may be positive.
Chronic small amounts of bleeding over a long period of time can lead to anemia.
Changes in bowel habits
There may be a feeling of incomplete bowel movement or a sense of urgency.
Increased frequency of bowel movements and smaller volume of stool at one time may occur.
Irregular stool shape, thin or long stools, and stubborn constipation and diarrhea may also occur.
Other symptoms
Abdominal pain
When the large adenoma pulls and causes the intestinal tube to be trapped or obstructed, abdominal distension and pain may occur.
Prolapse of mass
A large, low lying rectal adenoma with a tip may prolapse out of the anus during defecation.
Complications
Tubular villous adenomas may become cancerous.
Carcinoma
Some tubular villous adenomas may develop into malignant tumors and have a certain rate of cancer, the higher the villous component, the higher the rate of cancer.
Depending on the location, it can become colon cancer, rectal cancer and so on.
In the advanced stage, it mainly shows malignant state, with extreme thinness, deep-set eye sockets, loose skin, serious muscle atrophy, and “skin and bones” state.
Medical treatment
Department
Proctology
Physical examination reveals polyps or adenomas in the intestines, or symptoms such as blood in the stool, feeling of incomplete bowel movement, or a sense of urgency and heaviness, etc. It is recommended to consult a doctor in time.
General Surgery
General Surgery may also be consulted when the above symptoms occur.
Gastroenterology
Gastroenterology may also be consulted for symptoms such as blood in the stool.
Preparation
How to get to the doctor: registering, preparing documents, and common problems.
Tips for the doctor
It is recommended that you wear clothes that are easy to put on and take off before your visit so that you can be examined by the doctor.
Special reminder: Before visiting the doctor, you can take photos of any changes in stool texture, color, or discharge for the doctor’s review.
Preparation Checklist
Symptom Checklist
Pay special attention to the time of onset of symptoms, special manifestations, etc.
Are there any symptoms such as blood in the stool, feeling of incomplete bowel movement, or a feeling of urgency and heaviness?
Are there any symptoms such as abdominal pain, diarrhea, or constipation?
When did these symptoms start?
Are there any aggravating or relieving factors for these symptoms?
Medical History Checklist
Does anyone in the family have adenomas, malignant tumors of the GI tract?
Is there non-alcoholic fatty liver disease, chronic viral hepatitis, liver transplantation?
Are there any cases of inflammatory bowel disease, Barrett’s esophagus, Helicobacter pylori infection, gastric polyps, colorectal melanosis, schistosomiasis?
Do you have acromegaly, diabetes, overweight or obesity?
Do you stay up late or work night shifts?
Do you have long-term smoking and drinking habits?
Do you have bad dietary habits, such as high fat, high animal protein, high sugar diet, betel nut chewing, overeating?
Did you consume too much high sugar and sugary drinks during adolescence?
Is there chronic diarrhea and constipation?
Checklist
Test results in the past six months, which can be brought to the doctor’s office
Laboratory tests: blood biochemistry test, stool routine + occult blood test.
Imaging tests: Magnetic Resonance Imaging (MRI)
Endoscopy: gastroscopy, enteroscopy, proctoscopy
Pathologic examination: Histopathologic examination
List of medications used
Medication used in the last 3 months, if available in boxes or packages, carry with you to the doctor’s office
Pain medications: aspirin, ibuprofen, rofecoxib, celecoxib, tramadol, etc.
Diagnosis
Diagnosis is based on
medical history
Family history of adenomas, malignant tumors of the GI tract.
Having non-alcoholic fatty liver disease, chronic viral hepatitis, liver transplantation.
Have inflammatory bowel disease, Barrett’s esophagus, Helicobacter pylori infection, gastric polyps, colorectal melanosis, schistosomiasis.
Have acromegaly, diabetes, overweight or obesity.
Stay up late for a long time, smoke, drink alcohol.
Have bad dietary habits: high-fat, high-animal protein, high-sugar diet, chewing betel nut, overeating.
Intake of high sugar and sugary drinks during adolescence.
Prolonged diarrhea and constipation.
Clinical manifestations
Symptoms such as blood in the stool, change in bowel habit (feeling of incomplete defecation or feeling of urgency and heaviness in defecation, increased frequency of defecation) may occur.
Abdominal pain, diarrhea and constipation may also occur.
A mass may be palpable on rectal palpation, and the patient may have abdominal tenderness.
Laboratory Tests
Blood biochemistry
The patient’s lipid and glucose levels are evaluated.
Some patients with tubular villous adenoma may have higher than normal triglycerides, total cholesterol, uric acid, and lipid levels.
Stool routine + Occult blood test
Evaluate whether the patient has gastrointestinal bleeding, and assist in the diagnosis of tubular villous adenoma.
Fecal occult blood test is usually positive in patients with tubular villous adenoma.
Imaging
Magnetic resonance imaging (MRI)
Magnetic resonance imaging (MRI) can be used to visualize the location and shape of tubular villous adenoma, as well as the enlargement of the surrounding lymph nodes.
MRI of tubular villous adenoma may show thickening of the intestinal wall or soft tissue nodules or masses in the intestinal lumen, most of which are solitary, and the morphology is often rounded, lobulated, or flattened, with smooth edges of the tumor.
Precautions
Remove all metal objects from the body before the test.
If the patient has a metal pacemaker, stent, or steel plate in the body, the MRI should not be performed. If MRI is necessary, the staff must be told what kind of metal objects are in the body to assess whether the test can be performed.
Endoscopy
Gastroscopy, enteroscopy, proctoscopy
It can be more intuitive to understand the location and size of tubular choriocarcinoma, etc. The size, morphology and relationship with the surrounding tissues have a high degree of specificity and sensitivity.
It can also detect cancer and precancerous lesions at an early stage, and is also an important means of treating digestive tract lesions.
Pathologic biopsy or total tumor resection, sent to the pathology examination can clearly confirm the diagnosis.
There is a risk of complications such as bleeding.
During the examination, you should try to breathe deeply and relax your muscles to facilitate endoscopic access to the GI tract.
Histopathologic examination
It can clarify the nature of the lesion and is the gold standard for diagnosing tubular villous adenoma.
A portion of the tumor tissue is taken for histopathological examination during proctoscopy, which can clarify whether it is a tubular villous adenoma or not.
Sampling for histopathologic examination is invasive and complications such as bleeding can occur.
Differential Diagnosis
When considering tubular villous adenoma in the presence of abdominal pain, blood in the stool, and changes in bowel habits, care should be taken to differentiate it from the following diseases.
Colorectal cancer
Similarity: Both may present with symptoms such as blood in stool and change in bowel habit.
Differences
Colorectal cancer is a malignant tumor, which is hard and should not be pushed.
Symptoms such as pus-blood mucus stool and anal pain can also occur.
Histopathologic examination can find cancer cells, which can identify the two.
Colorectal lipoma
Similarity: both may present with abdominal pain.
Differences
Colorectal lipoma is a common benign disease of the gastrointestinal tract, usually associated with metabolic abnormalities and genetics.
Lipomas are soft, elastic, with clear borders and smooth surface mucosa.
Most of them can be initially diagnosed through enteroscopy with submucosal elevation and different tactile sensation.
And histopathological examination can directly clarify the type of tumor, which helps to identify.
Treatment
Treatment objective: maximize the resection of adenoma and prevent cancer.
Treatment principle: once diagnosed, early surgical treatment.
Surgery
The surgical treatment of tubular villous adenoma and colorectal adenoma is basically the same, mainly including endoscopic resection and transanal endoscopic microsurgery (TEM), transanal local resection.
Endoscopic resection
Indications
For broad-based adenomatous polyps with a tip or diameter <2cm, which can be removed endoscopically.
Contraindication
The patient cannot cooperate.
Bleeding tendency or use of antithrombotic drugs.
Severe cardiopulmonary disease or inability to tolerate endoscopic treatment.
Vital signs are unstable.
Reliable evidence of tumor infiltration into the lamina propria.
Patients with suspected deep submucosal infiltration.
Surgical approach
For tiny polyps (≤5 mm), resection is performed using a cold loop lancet.
For small polyps (6-9 mm), resection is performed with cold or hot loopers.
For adenomas >20 mm in diameter and early bowel cancer, endoscopic submucosal dissection (ESD) may be used.
Postoperative complications
Postoperative complications mainly include bleeding, perforation, electrocoagulation syndrome (abdominal pain at the surgical site, fever, elevated white blood cells, etc.) and abdominal discomfort.
Postoperative complications can also be non-gastrointestinal and are often related to the patient’s pre-existing condition.
Postoperative care
Post-operative cardiac monitoring is often required to closely monitor the heart rate and blood pressure, especially for the elderly and people with other heart, lung and kidney diseases.
Take rest after surgery and avoid forceful activities to prevent bleeding and aggravation.
Transanal endoscopic microsurgery (TEM)
Indications
Suitable for non-tibial, broad-based rectal adenoma whose tumor occupies less than 75% of the circumference of the rectal intestinal lumen.
Contraindication
TEM is contraindicated in patients with anal sphincter dysfunction to avoid postoperative anal incontinence.
Surgical complications
Transient fever, diarrhea, urinary retention, transient anal bleeding (including rectal wound bleeding or internal hemorrhoidal bleeding caused by anal dilatation) may occur, which often recovers on its own.
May also be complicated by rectal wound fissure, temporary anal incontinence, the general symptoms are mild, often in a few days to 3 months recovery.
In female patients, resection of the anterior wall of the lower and middle rectum is too deep, which may cause rectovaginal fistula.
Rarely, infectious shock may occur.
Transanal local excision
Indications
For patients with rectal adenomas >2cm in diameter, located within 7cm from the anus, and difficult to resect endoscopically.
Postoperative care
Postoperative resection specimen should be pathologically examined to make sure the margins are negative, otherwise additional surgery is required.
Postoperative cardiac monitoring is used to closely monitor the heart rate and blood pressure.
Pay attention to protect the incision and prevent bleeding.
Strictly follow the principle of asepsis, change the gauze at the incision in time and keep the incision dry.
When the incision is painful after surgery, ice can be applied or oral analgesic can be taken.
Medication
Painkillers
Relieve the pain and reduce the discomfort of patients.
Suitable for patients with tubular villous adenoma who present with abdominal pain symptoms.
Commonly used drugs: non-steroidal anti-inflammatory drugs (ibuprofen, rofecoxib, celecoxib), tramadol, etc.
Adverse reactions such as nausea, vomiting, dyspepsia, dry mouth, drowsiness, dizziness and constipation may occur.
Precautions
Try to alternate between different drugs rather than a single drug to avoid developing drug resistance.
Try to prolong the interval between medications after the pain has subsided.
Prognosis
Cure
Tubular choriocapillaris adenomas do not heal on their own and are usually not disabling.
The prognosis is better after timely surgical treatment to maximize the removal of the adenoma, but there is a possibility of recurrence.
Untreated or untimely standardized treatment, such as the development of cancer can be malignant, serious death.
Prognostic factors
The prognosis of tubular choriocapillaris adenoma is related to the structure of the villi, physical status, and the occurrence of carcinoma.
Chorionic structure: generally, the less chorionic component, the more benign the adenoma is, and the less malignant it is.
Physical status: patients with better physical fitness and physical status have a relatively better prognosis.
With or without cancer: the prognosis of tubular choriocarcinoma without cancer is better.
Harmfulness
Patients with tubular villous adenoma experience symptoms such as blood in the stool, diarrhea, constipation, etc., which reduces physical ability and affects daily life.
Tubular villous adenoma may become cancerous and threaten the patient’s life.
Daily
Daily management
Dietary management
Avoid overeating and eat in moderation.
Rationalize the diet and eat more nutritious and easy-to-digest foods, such as black fungus and shiitake mushrooms.
Consume more fresh fruits and vegetables rich in dietary fiber and vitamins, such as celery, bananas and apples.
Eat less high-fat food such as fatty meat; eat less spicy and stimulating food such as chili, garlic, mutton, barbecue, etc.
Life management
Avoid exertion, pay attention to rest and ensure sufficient sleep.
Appropriate exercise is needed in daily life to improve physical fitness and avoid low immunity.
Psychological support
Regulate the emotion, make the mood cheerful and good, mentally active.
Accept health education to understand the knowledge about tubular choriocapillaris adenoma and correct the wrong perception of the disease.
In case of emotional instability and psychological depression, confide in friends and relatives, or seek help from medical personnel.
If necessary, professional psychological counseling should be conducted to avoid affecting the therapeutic effect due to psychological problems.
Relatives of the patient need to pay attention to the patient’s psychological changes in daily life.
Disease monitoring
Patients should seek medical attention when they develop symptoms such as abdominal pain, blood in the stool, or change in bowel habits.
Patients who undergo surgery need to pay attention to the indicators of cardiac monitoring after surgery and closely monitor the heart rate and blood pressure.
Surgically treated tubular villous adenoma patients need to strictly follow the doctor’s instructions for regular review to prevent recurrence.
Follow-up examination
Importance of follow-up
For patients with tubular choriocapillaroma, follow-up examinations are crucial to monitor the changes of the disease and whether there is any recurrence or cancer.
Timing of follow-up
For patients with tubular choriocapillaris adenoma, it is recommended to review colonoscopy within 1 year after surgery [3].
Tests to be done at the time of review
Review generally performs fecal occult blood test, MRI, proctoscopy and so on.
Prevention
Abstain from smoking and alcohol, eat a healthy diet, do not eat burnt and burnt foods, and eat less high-fat, high-protein, and high-sugar foods.
Teenagers avoid excessive intake of high sugar and sugary drinks.
Try to diversify food intake and consume more high-fiber foods such as vegetables and fruits.
Patients with NAFLD should actively treat the primary disease and avoid long-term inflammatory stimuli [3].
Moderate-intensity exercise is recommended, i.e., at least 30 min per session for more than 5 days per week.
People with abnormal defecation (unpleasant stools, frequent defecation, change in stool properties, blood in stools, etc.), old age, and family history of adenomas and malignant tumors of the digestive tract should have regular physical examinations, checking the stool routine, fecal occult blood test and filling out questionnaires, and gastroenteroscopy if necessary, for timely detection.