消化道早癌的诊断

1、消化道早癌内镜诊疗1/3/25第1页概 述诊 断治 疗2第2页发觉早癌内镜诊疗技术白光内镜检验。染色内镜检验。白光放大（ME）。染色+放大。ME+NBI (magnified endoscopy)。活检超声内镜。共聚焦显微内镜。自体荧光内镜光学相干断层成像术细胞内镜蓝激光成像3第3页白光内镜发觉早癌前提理想消化内镜术前检验准备：清理视野，抵制蠕动。严格质量控制。时刻准备发觉早癌警觉性。特殊、小病变，可借助特殊内镜诊疗方法。活检。4第4页一、染色内镜最惯用染料：碘染色：食管黏膜染色。0.1-0.4%靛胭脂：对比性染料，惯用于腺瘤。0.1-0.2%美蓝(亚甲蓝)：吸收性，惯用于腺瘤。0.05%结晶

2、紫（龙胆紫）：吸收性，惯用于侵袭性病变染色。在病变表面滴数滳，然后再用温水冲洗。最好用链霉蛋白酶。5第5页表1 消化内镜下惯用染料染料类型被染对象染色原理阳性颜色临 床 应 用Lugols碘液(碘+碘化钾)磷状上皮内糖原非角化上皮结合碘深棕色正常食管磷状上皮着色。食管磷状细胞癌黏膜、Barrett食管黏膜、柱状上皮和食管炎黏膜均不着色。亚甲蓝肠道上皮细胞，肠化上皮细胞吸收入上皮细胞内蓝色食管和胃肠化上皮、早期胃癌上皮和正常肠道上皮着色。十二指肠内化生胃上皮不着色。甲苯胺蓝胃或肠内柱状上皮细胞胞核差色自由扩散入细胞蓝色食管磷状细胞癌上皮和Barrets食管中化生上皮着色刚果红胃内泌酸细胞当pH3

3、.0时变色变为深蓝或黑色泌酸胃上皮变色，包含异位胃黏膜上皮。胃癌上皮细胞不变色。酚红感染HP胃上皮细胞因为HP周围有“氨云”，局部呈碱性而便酚红变色由黄变红诊疗胃内HP感染及其分布情况。靛胭脂细胞不着色沉积于上皮表面低凹处，勾勒出病变形态。蓝色全消化道黏膜均可使用。6第6页Conventional white light imagingIndigo carmine chromoendoscopy7第7页Indigo carmine8第8页Indigo carmine结晶紫：结构消失，侵及黏膜下层。 白光内镜：7mm扁平息肉样隆起靛胭脂：中央凹陷9第9页二、特殊光谱及放大内镜C-WLI: 20-

4、40倍ME: 80-170倍Magnifying endoscopy (ME)Narrow band imaging10第10页11第11页12第12页13第13页EP, epithelium; LPM, lamina propria mucosae; MM, muscularis mucosae; SM, submucosa; PM, proper muscle; M1, cancer is limited epithelium; M2, cancer invades LPM but does not reach MM; M3, cancer invasion reaches MM; SM,

5、 submucosally invasive cancer14第14页15第15页16第16页NBI imaging of a lesion of IPCL type III. NBI imaging of a lesion of IPCL type IV regional atrophic mucosa or low grade intraepithelial neoplasia high-grade intraepithelial neoplasia：Tis 17第17页This pattern is called IPCL-V1. IPCL-V1 includes four major

6、characteristic morphological changes of IPCL: dilation, meandering, irregular caliber, and figure variation. T1a.18第18页This is typical image of intrapapillary capillary loop (IPCL)-V3. Cancer invasion depth was M3 (muscularis mucosae: T1a).19第19页Large white arrows point to large tumor vessel (IPCL-V

7、N). The striking morphological feature is its extra-large diameter. Note the difference of vessel caliber between IPCL-V3 (small white arrow) and VN (large white arrow: T1b or deeper). 20第20页V: microvascular pattern Subepithelial capillary (SEC) Collecting venule (CV) Pathological microvessels (MV)S

8、: microsurface pattern Marginal crypt epithelium (MCE) Crypt opening (CO) Intervening part (IP) between crypts21第21页MNBI, magnifying endoscopy with narrow-band imaging; LBC, lightblue crestSECN, subepithelial capillary network; RAC, regular arrangement of collecting venules; CO, crypt-opening; MCE,

9、marginal crypt epithelium;CV, collecting volumeYao K. Ann Gastroenterol. ;26(1):11-22.(A, B) Normal gastric body mucosa. (C) Helicobacter pylori-associated gastritis. (D)Atrophic gastritis. ABCD22第22页C-WLI :erosionM-NBI: a regular microvascular pattern and a regular microsur-face pattern with light

10、blue crest. chronic gastritis with intestinal metaplasia23第23页C-WLI: 轻微凹陷。M-NBI：irregular MV and MS with a clear demarcation line.Histopathological findings: a well-differentiated adenocarcinoma confined to the mucosa24第24页Pit pattern classification (1)Kudo分型(pit pattern).分为5型（Type I to type V）：Type

11、 I and II ：良性，非肿瘤性。type III to V：肿瘤性，其准确率达90%。Type III：III-S and III-L25第25页26第26页血管袢(CP，sano)分型(佐野分型)CP分型分为I, II, III型，其中III型又分为A和B两亚型。NBI加放大能有效识别低级别上皮内瘤变和高级别上皮内瘤变或浸润性癌。能有效预测病变组织学类型。27第27页Modified 3-step strategy of NBI colonoscopy.28第28页(a) 普通光下观察，乙状结肠息肉，0.4cm，表面无显著平坦改变(b) NBI：NBI放大下见显著凹陷，pit patt

12、ern为IIIB（佐野分型）提醒有黏膜下侵犯，肉眼观呈“0-I s + II c”,这种病变易出现黏膜下侵犯。(c)结晶紫染色：呈VNpits，为浸润性改变，强烈提醒深度黏膜下层侵犯。外科手术。(d)病剪发觉：中分化腺癌. 两个小、非侵袭性结直肠癌(5mm). 29第29页(a)普通白光：降结肠0.5cm小息肉，无显著凹陷。(b) NBI：NBI+ME见病变中央凹陷，pit pattern为Sano分型B型说明可能为浸润性癌，需深入行结晶紫染色。(c)结晶紫染色：腺管开口呈浸润癌特征，但因中央凹陷太小，不愿定，内镜下切除，为高分化腺癌，再行外科手术.30第30页图 1. 现有结直肠息肉 NIC

13、E 分类31第31页Typical endoscopic findings of NICE classificationFigures to illustrate the NBI International Colorectal Endoscopic (NICE) classification.32第32页33第33页三、其它内镜检验EUS：共聚焦内镜34第34页EUS：20MHzEUSTis High-grade dysplasiaT1 Tumor invades the lamina propria, muscularis mucosae (T1a) or submucosa (T1b),

14、 but does not breach the submucosaT2 Tumor invades the muscularis propria, but does not breach the muscularis propriaT3 Tumor invades the adventitiaT4 Tumor invades adjacent structures; T4a: resectable tumor invading the pleura, pericardium, or diaphragm, T4b: unresectable tumor invading other adjac

15、ent structures, such as aorta, vertebral body, trachea, etc.35第35页Confocal Endomicroscopy in normal colonic epitheliumConfocal Endomicroscopy in a colonic dyspalsia36第36页五、内镜下活检37第37页我科胃癌早期筛查流程38第38页 六、胃蛋白酶原与胃癌Riecken B. Prev Med,胃蛋白酶原（pepsinogen，PG）PG：由胃底腺主细胞和颈粘液细胞分泌PG：除了胃底腺，胃窦幽门腺和近端十二指肠Brunner腺也能分泌PGR： PG / PGPG法用于胃癌筛查，已被多部共识意见推荐缺点：阳性预测值较低反应胃体萎缩PG IPGRFock KM. J Gastroenterol Hepatol ; 中华消化内镜杂志 39第39页高胃泌素血症、PGR低值是非贲门胃癌高危原因（肠型胃癌）。40第40页Vnnen. Eur J Gastroenterol Hepatol A 组B 组C 组G-17-+-+PG-+血清PG联合G-17G-17(+)：G-17 1pmol/L或G-17 15pmol/LPG（+）：PG 70ng/ml 且PGR