1、消化道早癌的内镜诊断12020/3/25概 述诊 断治 疗22022-10-21发现早癌的内镜诊断技术白光内镜检查。染色内镜检查。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32022-10-21白光内镜发现早癌的前提理想的消化内镜术前检查的准备：清理视野，抵制蠕动。严格的质量控制。时刻准备发现早癌的警觉性。特殊、小病变，可借助特殊内镜诊断方法。活检。42022-10-21一、染色内镜最常用的染料：最常用的染料：碘染色：碘染色：食管黏膜染色。0.1-0.4%0.1-0.4%靛
2、胭脂：靛胭脂：对比性染料，常用于腺瘤。0.1-0.2%0.1-0.2%美美蓝蓝(亚甲蓝亚甲蓝)：吸收性，常用于腺瘤。0.05%0.05%结晶紫（龙胆紫）结晶紫（龙胆紫）：吸收性，常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。52022-10-21表表1 1 消化内镜下常用消化内镜下常用染料染料染料类型染料类型被染对象染色原理阳性颜色临 床 应 用LugolsLugols碘碘液液(碘碘+碘化钾碘化钾)磷状上皮内的糖原非角化上皮结合碘深棕色a)正常食管磷状上皮着色。b)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。亚甲蓝亚甲蓝肠道上皮细胞，
3、肠化上皮细胞吸收入上皮细胞内蓝色a)食管和胃的肠化上皮、早期胃癌上皮和正常肠道上皮着色。b)十二指肠内化生的胃上皮不着色。甲苯胺蓝甲苯胺蓝胃或肠内的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食管中的化生上皮着色刚果红刚果红胃内泌酸细胞当pH3.0时变色变为深蓝或黑色a)泌酸的胃上皮变色，包括异位胃黏膜上皮。b)胃癌上皮细胞不变色。酚红酚红感染HP的胃上皮细胞由于HP周边有“氨云”，局部呈碱性而便酚红变色由黄变红诊断胃内HP的感染及其分布情况。靛胭脂靛胭脂细胞不着色沉积于上皮表面的低凹处，勾勒出病变形态。蓝色全消化道黏膜均可使用。62022-10-21Convent
4、ional white light imagingIndigo carmine chromoendoscopy72022-10-21Indigo carmine82022-10-21Indigo 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92022-10-21二、特殊光谱及放大内镜C-WLI:20-40倍ME:80-170倍Magnifying endoscopy Magnifying endoscopy(ME)(ME)Narrow band imaging102022-10-21112022-10-21122022-10-21132022-1
5、0-21EP,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,submucosally invasive cancer142022-10-21152022-10-21162022-10-21NBI imaging of a lesion of IPC
6、L type III.NBI imaging of a lesion of IPCL type IV regional atrophic mucosa or low grade intraepithelial neoplasia high-grade intraepithelial neoplasia：Tis 172022-10-21This pattern is called IPCL-V1.IPCL-V1 includes four major characteristic morphological changes of IPCL:dilation,meandering,irregula
7、r caliber,and figure variation.T1a.182022-10-21This is typical image of intrapapillary capillary loop(IPCL)-V3.Cancer invasion depth was M3(muscularis mucosae:T1a).192022-10-21Large white arrows point to large tumor vessel(IPCL-VN).The striking morphological feature is its extra-large diameter.Note
8、the difference of vessel caliber between IPCL-V3(small white arrow)and VN(large white arrow:T1b or deeper).202022-10-21V:microvascular pattern Subepithelial capillary(SEC)Collecting venule(CV)Pathological microvessels(MV)S:microsurface pattern Marginal crypt epithelium(MCE)Crypt opening(CO)Interveni
9、ng part(IP)between crypts212022-10-21MNBI,magnifying endoscopy with narrow-band imaging;LBC,lightblue crestSECN,subepithelial capillary network;RAC,regular arrangement of collecting venules;CO,crypt-opening;MCE,marginal crypt epithelium;CV,collecting volumeYao K.Ann Gastroenterol.2013;26(1):11-22.(A
10、,B)Normal gastric body mucosa.(C)Helicobacter pylori-associated gastritis.(D)Atrophic gastritis.ABCD222022-10-21(A)C-WLI:erosion(B)M-NBI:a regular microvascular pattern and a regular microsur-face pattern with light blue crest.(C)chronic gastritis with intestinal metaplasia232022-10-21(A)C-WLI:轻微凹陷。
11、(B)M-NBI：irregular MV and MS with a clear demarcation line.(C)Histopathological findings:a well-differentiated adenocarcinoma confined to the mucosa242022-10-21Pit pattern classification(1)Kudo分型(pit pattern).分为5型（Type I to type V）：Type 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
12、III-L252022-10-2126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。能有效预测病变的组织学类型。272022-10-21Modified 3-step strategy of NBI colonoscopy.282022-10-21(a)普通光下观察，乙状结肠息肉，0.4cm，表面无明显平坦变化(b)NBI：NBI放大下见明显凹陷，pit pattern为IIIB（佐野分型）提示有黏膜下侵犯，肉眼观呈“0-I s+II c”,这种病变易出现黏膜下侵犯。(
13、c)结晶紫染色：呈VN pits，为浸润性改变，强烈提示深度黏膜下层侵犯。外科手术。(d)病理发现：中分化腺癌.两个小的、非侵袭性结直肠癌(5mm).292022-10-21(a)普通白光：降结肠0.5cm的小息肉，无明显凹陷。(b)NBI：NBI+ME见病变中央凹陷，pit pattern为Sano分型的B型说明可能为浸润性癌，需进一步行结晶紫染色。(c)结晶紫染色：腺管开口呈浸润癌特征，但因中央凹陷太小，不肯定，内镜下切除，为高分化腺癌，再行外科手术.302022-10-21图 1.现有结直肠息肉的 NICE 分类312022-10-21Typical endoscopic finding
14、s of NICE classificationFigures to illustrate the NBI International Colorectal Endoscopic(NICE)classification.322022-10-21332022-10-21三、其它内镜检查EUS：共聚焦内镜342022-10-21EUS：20MHzEUSEUSTis High-grade dysplasiaT1 Tumor invades the lamina propria,muscularis mucosae(T1a)or submucosa(T1b),but does not breach t
15、he 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 adjacent structures,such as aorta,
16、vertebral body,trachea,etc.352022-10-21Confocal Endomicroscopy in normal colonic epitheliumConfocal Endomicroscopy in a colonic dyspalsia362022-10-21五、内镜下活检372022-10-21我科胃癌的早期筛查流程382022-10-21 六六、胃蛋白酶原与胃癌胃蛋白酶原与胃癌Riecken B.Prev Med,2002胃蛋白酶原（胃蛋白酶原（pepsinogen，PG）PG：由胃底腺的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
17、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PG IPGRFock KM.J Gastroenterol Hepatol 2008;中华消化内镜杂志中华消化内镜杂志 2014392022-10-21高胃泌素血症、PGR低值是非贲门胃癌的高危因素（肠型胃癌）。402022-10-21Vnnen.Eur J Gastroenterol Hepatol 2003 A 组组B 组组C 组组G-17-+-+PG-+血清血清PG联合联合G-17lG-17(+)G-17(+)：G-17 G-17 1pmol/L 1pmol/L或或G-17 G-17
18、15pmol/L15pmol/LlPGPG（+）：）：PG 70ng/ml PG 70ng/ml 且且PGR 7.0PGR 7.0胃癌风险递增胃癌风险递增412022-10-21体检人群检测血清PGI、PGII、PGR、G-17B组：组：“G-17(+)且PG(-)”或“G-17(-)且PG(+)”C组：组：“G-17(+)且PG(+)”A组：组：“G-17(-)且PG(-)”存在较低胃癌风险存在较低胃癌风险胃癌高风险胃癌高风险进展期进展期胃癌胃癌胃癌风险低胃癌风险低不建议胃镜检查可根据临床需要，行胃镜检查胃镜精查早期胃癌，早期胃癌，或高级别或高级别瘤变瘤变非胃癌非胃癌其他其他重度萎缩、重度萎缩、肠化和低肠化和低级别瘤变级别瘤变定期复查PG、G-17ESD等微创治疗外科手术每年行胃镜检查每年复查PG、G-17每年行胃镜检查422022-10-21432022-10-21
