Endoscopic diagnosis and treatment of upper gastrointestinal tumors

Early diagnosis, endoscopic differentiation of benign from malignant lesions, and removal of clinically significant tumors are increasingly considered to be major topics of interest in the upper gastrointestinal tract. This interest is mainly due to the development of better imaging tools and new resection techniques that fulfill surgical criteria. At this year's Digestive Disease Week (DDW; 7-10 May 2011, Chicago, Illinois, USA), more than 500 abstracts were presented that focused on better imaging, training, safety issues, luminal stenting, and indications and results in endoscopic submucosal dissection (ESD). This review highlights a selection of clinically relevant reports of the upper gastrointestinal tract, excluding Barrett's esophagus, which is covered in a separate report. Related abstracts that are not discussed in this review can be found in the additional references of interest.     

上消化道类癌的内镜诊断及病理分析

目的探讨上消化道类癌的内镜诊断及病理特点。方法回顾性分析2000年1月-2007年3月18例上消化道类癌的临床资料。结果18例上消化道类癌包括食管类癌4例；胃类癌12例；十二指肠类癌2例，其中，术前经内镜确诊5例。9例行免疫组织化学检查。结论内镜检查是术前诊断上消化道类癌的重要手段；特殊类型类癌确诊须依赖免疫组织化学检查。     

血液透析过程中并发上消化道出血的急诊内镜下诊治探讨

目的探讨血液透析过程中并发急性上消化道出血患者急诊内镜下的表现及止血措施。方法对48例血液透析过程中并发急性上消化道出血患者进行急诊内镜检查及治疗,总结消化道出血原因、内镜下表现、内镜下治疗方法及疗效。结果急诊胃镜检查发现上消化道出血病因以胃黏膜糜烂出血为主20例(41.7%),其次为十二指肠球部溃疡12例(25.0%)、胃溃疡8例(16.7%)。幽门螺旋杆菌阳性36例(75.0%)。上消化道出血内镜下改良Forrest分级:ForrestⅠa 6例,ForrestⅠb 18例,ForrestⅡa 8例,ForrestⅡb 8例,ForrestⅡc 4例,ForrestⅢ4例。对分级为ForrestⅠa至ForrestⅡb的38例患者进行内镜下止血,包括喷洒止血药止血6例,注射止血药止血4例,高频电凝止血8例,氩离子凝固术10例,钛夹止血6例,多种方法联合应用4例。48例患者中上消化道出血治愈46例,死亡2例,总体即时止血率为63.2%,有效止血率31.6%,再发出血率5.3%。结论血液透析中并发急性上消化道出血以急性胃黏膜糜烂为主,内镜下表现以ForrestⅠb及ForrestⅡb为主,急诊内镜下止血效果显著。     

血清腹水白蛋白梯度在腹水临床诊断中的价值

目的比较血清腹水白蛋白梯度与渗出液／漏出液对腹水鉴别诊断的准确性。方法选择诊断明确腹水病例53例,将其分为门脉高压组（A组,n=30）及非门脉高压组（B组,n=23）。比较传统的渗漏出液的分类方法及以血清腹水白蛋白梯度方法对腹水病因诊断的准确率。结果血清腹水白蛋白梯度的诊断准确性为94．34％,敏感性96．67％,特异性为91．31％,高于传统的渗漏出液指标的准确率。结论将腹水依据血清腹水白蛋白梯度判定为门脉高压相关性及非门脉高压相关性,在临床上将具有更强的实用性及更广泛的应用价值。     

Laparoscopic diagnosis of tuberculous ascites

We report 14 patients with tuberculous peritonitis presenting as persistent and exudative ascites. We found a primary site of tuberculous infection in only 10% of the patients. PPD test was positive in 9 patients. Ascitic fluid showed a protein content in excess of 3.5 g/dl. and more than 300 cells/mm3, mainly lymphocytes, in all patients, Ziehl stain and the culture for Tb. bacilli were negative in all cases. The confirmatory diagnosis was made by laparoscopy and peritoneal biopsy. Good views were obtained on all occasions, and there was no morbidity. Appearances were similar in all cases. Multiple white tubercles were scattered over the parietal and visceral peritoneum. filmy adhesions were present. Four patients had cirrhotic liver disease confirmed by laparoscopy. The biopsy specimen showed caseating granulomata, and the auramine stain was positive in four cases. We conclude that laparoscopy and biopsy is a safe and effective method of obtaining an early diagnosis in patients with tuberculous ascites, especially if they also have cirrhosis.     

Endoscopic ultrasound of the upper gastrointestinal tract

Endoscopic ultrasound (EUS) is an evolving technique used by gastroenterologists to examine lesions that are located either within or adjacent to the walls of the upper gastrointestinal (GI) tract; this topic is relatively unknown to most radiologists. Proper use of this modality is benefited by a cooperative effort between gastroenterologists and radiologists specializing in ultrasound and cross-sectional imaging. This article informs radiologists of the applications of this procedure. Most patients are examined with EUS after a biopsy of a mucosal tumor has been performed. A smaller number are performed to evaluate submucosal masses or when pancreatic disease is suspected but not diagnosed. The examinations can be performed either with dedicated flexible echoendoscopes or with catheter-based probes passed through a conventional endoscope. The exact location of abnormalities associated with the upper GI tract can be observed. Known anatomic landmarks are sought. Abnormalities of structures outside the upper GI tract will occasionally be found during these examinations. The specific layers of the walls of the gut are examined, and the T and N-classification of upper GI tumors can be determined accurately. The performance of an EUS examination requires advanced skills, and in many medical centers, it is the imaging modality of choice to stage cancers, to evaluate submucosal masses, and to investigate both malignant and benign pancreaticobiliary disease. Endoscopic ultrasound is sensitive but not specific, and biopsy is necessary to establish a diagnosis. Therapeutic applications of EUS are evolving. Specialized applications with catheter-based probes are also being developed.     

Endoscopic diagnosis of ulcerative colitis

Endoscopic findings of ulcerative colitis are classified into three groups according to the degree of inflammation, i.e. mild, moderate and severe. 1)mild: Edema, erythema, yellow spots, fine granular appearance are conspicuous signs of early disease. The mucosal vascular pattern disappears. 2)moderate: Coarse mucosa with mucous, pus, blood are characteristic findings. Erosions or shallow ulcers are scattered. The erythematous mucosa is friable and bleeds easily. 3)severe: There are deep, widespread ulcers. Marked bleeding is seen from granulation tissue of ulcer base. We remind that inflammation often take a turn for the worse due to endoscopic examination. Total colonoscopy is not always necessary in the cases of ulcerative colitis.     

Endoscopic diagnosis of Barrett's esophagus

In Japan Barrett's mucosa is defined as columnar lined esophagus (CLE). The prevalence of Barrett's esophagus and Barrett's adenocarcinoma is very low. But in Western countries Barrett's mucosa is defined as CLE with intestinal metaplasia, and many cases of Barrett's esophagus and Barrett's adenocarcinoma are reported. The definite endoscopic diagnosis of Barrett's mucosa cannot be so easy. We investigated the positional relationship between the esophageal hiatus, squamo-columnar junction, and longitudinal vessels in persons who underwent esophagogastroduodenoscopy. Subepithelial longitudinal vessels were found at the lower esophagus in all cases. In no cases were the longitudinal vessels observed under the gastric mucosa beyond the esophageal hiatus. It is peculiar to the esophagus to be able to observe subepithelial longitudinal vessels in the vicinity of the esophago-gastric junction. When longitudinal vessels are found only under the columnar epithelium at the oral side over the esophageal hiatus from the stomach, this indicates Barrett's epithelium. Thus the definite diagnosis of Barrett's epithelium can be made by endoscopy.