Primary malignant disease of the duodenum is accompanied by two varieties of symptoms, one of which is common to all cases, while the other varies with the situation of the growth. The former comprises progressive emaciation, cachexia, loss of appetite, vomiting, haematemesis or melaena, constipation alternating with diarrhoea and pain in the abdomen after meals, with the signs of dilatation of the stomach, and perhaps a palpable tumour. The latter, or localising symptoms, on the other hand, consist of jaundice with enlargement of the liver and distension of the gall-bladder, attacks of intestinal obstruction, vomiting of bile and pancreatic juice, the presence of a chromogen in the urine, and the signs of dilatation of the stomach and duodenum.
Disease of the first part of the duodenum has to be distinguished from benign and malignant strictures of the pylorus, and from the effects of pressure exerted upon the bowel by an external tumour.
1. Pyloric stenosis due to the cicatrisation of a simple ulcer develops very gradually, and is seldom accompanied by rapid emaciation or cachexia. There is almost .always a history of previous severe pain after food, with one or more attacks of haematemesis. Pain and acidity are chiefly experienced during the night, and the vomit may be stained with bile. Free hydrochloric acid is present in excess, and the existence of hypersecretion may be determined by evacuating the stomach in the early morning. Although the viscus may be greatly dilated and hypertrophied, no tumour can be felt, and if suitable treatment is adopted the general health may continue good for many years.
2. From cancer of the pylorus the diagnosis is very difficult, since the symptoms and signs of the two diseases are practically identical. It is stated, however, that when cancer attacks the upper duodenum the appetite is less affected than in the gastric complaint, that free hydrochloric acid may continue for a considerable time, that bile is not infrequent in the vomit, and that diarrhoea is apt to alternate with constipation. If a tumour is present, it is usually situated more to the right of the median line than is the case with a pyloric growth.
3. Pressure upon the first part of the duodenum may be caused by an enlarged gall-bladder, a tumour of the liver, an aneurysm of the cceliac axis or of the hepatic artery, or by a growth of the omentum, kidney, pancreas, or retro-peritoneal glands. These forms of obstruction develop more slowly and are less severe than that produced by cancer of the duodenum. Haematemesis and cachexia are rare, and the loss of flesh is often proportional to the urgency of the gastric symptoms. The tumour varies in its character and attachments according to its mode of origin, and free hydrochloric acid may usually be detected in the gastric contents.
Malignant disease of the second part of the duodenum may be confused with cancer of the pancreas or of the ampulla of Vater, with gallstones, and with a simple chronic ulcer in the same situation.
1. A growth of the head of the pancreas, or of the small diverticulum into which the common bile and pancreatic ducts open (ampulla of Vater), is accompanied from the first by jaundice, which soon becomes intense, and usually persists throughout the whole course of the disease. The gastric phenomena, on the other hand, are of subordinate importance, and mainly consist of flatulence after meals, a bitter taste in the mouth, and inability to digest fats. The stomach is not dilated, there is no periodic vomiting, bile is absent from the stools, and the secretion of hydrochloric acid usually persists.
2. Gallstones are more common in women than in men, while the reverse is the case with duodenal cancer. The jaundice is preceded by severe spasmodic pain, and may continue for several months without seriously affecting the general health. Even when emaciation is a marked feature of the case, the patient does not usually display that loss of energy and physical debility which is so constant in cancer of the digestive organs. Periodic vomiting, with the signs of dilatation of the stomach, is absent, there is no haematemesis or melaena, and the initial enlargement of the gall-bladder disappears after a short time.
3. Simple chronic ulcer of the duodenum is usually accompanied by pain some hours after food, with tenderness on pressure above and to the right of the navel, and by occasional attacks of melaena, with or without haematemesis. Loss of flesh and appetite is an unimportant symptom, and the degree of anaemia varies with the severity of the haemorrhage. Should the disease ultimately produce stenosis of the bowel, the gastric dilatation is accompanied by hyperchlorhydria.
Obstruction of the third part of the duodenum may arise from other causes than malignant stricture, since a tumour of any neighbouring viscus may exert pressure upon the bowel. It is also possible that undue tension of the transverse mesocolon, or enlargement of the superior mesenteric vessels, may compress this portion of the gut. Of the internal diseases, the impaction of a gall-stone and the cicatrisation of a simple ulcer are the most important. In all these cases, however, the antecedent symptoms differ greatly from those of duodenal carcinoma ; there is seldom cachexia or rapid loss of flesh, and the discovery of a tumour helps to elucidate the nature of the primary disease. A gastro-biliary fistula is also accompanied by vomiting of bile, but there is usually a history of gallstones, while dilatation of the stomach and duodenum is absent.
This must be conducted upon the same lines as that of cancer of the pylorus. Lavage should be performec night and morning, the bowels maintained in regular action and the diet adjusted to the necessities of the patient. Excisior of the growth is rarely feasible, but gastro-enterostomy offer prolongs life for several months.