胆囊隆起性病变研究进展

胆囊隆起性病变研究进展深圳市东湖医院（５１８０２８）刘艳胆囊隆起性病变也称息肉样病变（ＧＢＰＬ）或称胆囊瘤样病变，是一组胆囊壁向腔内呈息肉样突出而局限性的一类病变的总称，包括肿瘤性或非肿瘤性、良性或恶性病变。近年来，随着Ｂ超诊断技术的广泛应用，这种病...     

不同结肠息肉内窥镜资料和癌变率的回顾性对比分析

本回顾分析了本院1986年1月至1996年6月经活检、电切及手术病理证实的426例结肠息肉病人，共583枚息肉。结果显示：最常见的为炎性息肉、其次为管状腺瘤；息肉好发部位为直肠和乙状结肠。息肉好发年龄在50—69岁肿瘤性息内的平均年龄较肿瘤样息肉明显为高，而腺瘤癌变平均年龄更高；各种肿瘤性息内和幼年性息肉的直径均较炎性息肉和血吸虫卵性息肉等为大，而腺瘤癌变直径更大；本组病例中发生癌变均为腺瘤性息肉，占腺瘤病人的3．99％，其中管状腺瘤、乳头状腺瘤，混合性腺瘤癌变率分别为1．72“，30“、25％，女性乳头状腺瘤癌变率则高选44．44％。这提示对于年龄较大，息肉直径较大，腺瘤样息内，尤其是乳头状腺瘤及混合性肿瘤应高度警惕其癌变可能，对女性乳头状腺瘤更要特别注意。     

不同结肠息肉内窥镜资料和癌变率的回顾性对比分析

本文回顾分析了本院1986年1月至1996年6月经活检、电切及手术病理证实的426例结肠息肉病人,共583枚息肉。结果显示:最常见的为炎性息肉、其次为管状腺瘤;息肉好发部位为直肠和乙状结肠。息肉好发年龄在50—69岁,肿瘤性息肉的平均年龄较肿瘤样息肉明显为高,而腺瘤癌变者平均年龄更高;各种肿瘤性息肉和幼年性息肉的直径均较炎性息肉和血吸虫卵性息肉等为大,而腺瘤癌变者直径更大;本组病例中发生癌变者均为腺瘤性息肉,占腺瘤病人的3.99%,其中管状腺瘤、乳头状腺瘤、混合性腺瘤癌变率分别为1.72%、30%、25%,女性乳头状腺瘤癌变率则高达44.44%。这提示对于年龄较大,息肉直径较大,腺瘤样息肉,尤其是乳头状腺瘤及混合性肿瘤应高度警惕其癌变可能,对女性乳头状腺瘤更要特别注意。     

胆囊息肉样病变的诊断与治疗胆囊息肉样病变的病因及发病机理

胆囊息肉样病变(PLG)又称胆囊隆起性病变，是指向胆囊内突出的局限性、息肉样、隆起性病变的总称。多为良性病变，分为非肿瘤性、肿瘤性两大类，大部分为非肿瘤性息肉样病变；常见的如胆固醇样息肉、炎性息肉，少见的如腺肌性增生、黄色肉芽肿、异位胃粘膜或异位胰腺组织。肿瘤样息肉病变常见的包括肿瘤和腺癌，此外血管瘤、脂肪瘤、平滑肌瘤、神     

老年胆囊切除患者结直肠腺瘤临床特点分析

目的了解老年胆囊切除患者结直肠腺瘤的临床特点,为老年结直肠癌的防治提供参考。方法纳入经肠镜检查发现息肉并行病理学检查提示为结直肠腺瘤的老年患者共1 272例,除外恶性肿瘤、家族性腺瘤性息肉病、炎症性肠病。根据既往有无行胆囊切除手术分为胆囊切除组和对照组,比较两组患者结直肠腺瘤的数量、大小、发生部位、病理类型,并比较胆囊切除时间不同亚组的结直肠腺瘤的特征。结果胆囊切除组女性患者比例明显高于对照组(P0.05);吸烟患者比例明显低于对照组(P0.05);腺瘤个数多于对照组(P0.05);绒毛状腺瘤比例高于对照组(P0.05)。恶变高风险息肉在胆囊切除时间不同的两个亚组中的比例差异无统计学意义(P0.05)。结论尽管与胆囊切除时间长短无关,老年胆囊切除患者结直肠腺瘤具有更高的恶变风险。     

胆囊占位病变中P53和K-ras的表达及其临床意义

目的:研究P53和K-ras蛋白在胆囊良性占位病变和胆囊癌组织中的表达及差异, 探讨其临床意义.方法:应用免疫组织化学方法检测20例胆固醇息肉、22例胆囊腺瘤、25例胆囊癌(含有5例重度非典型增生原位癌)组织中P53和K-ras蛋白的表达, 进行统计学分析.结果:胆囊良性病变的黏膜组织中存在P53和K-ras的异常表达, 其中, 胆囊腺瘤患者的阳性表达显著高于胆囊胆固醇息肉患者(72.7% vs35.0%, P = 0.014; 90% vs 75.0%, P = 0.167); 胆固醇性息肉患者的P53和K-ras表达较低. 配对比较的P53和K-ras表达结果无差异, 两者可能在胆囊癌的发生过程中有协同性作用.结论:胆固醇性息肉、胆囊腺瘤、胆囊癌患者的病变组织中P53和K-ras蛋白的表达有显著性差异, 表达阳性率呈现上升趋势.     

胆囊腺瘤的诊断与治疗

中华消化杂志编辑部：胆囊腺癌是真性肿瘤，R前认为系癌前病变。我院10年来送病理检查的胆囊切除标本949例中，病理证实息肉样病变88例，其中胆囊腺瘤12例，占息肉样病变的13．6％（12／88），占同期胆级切除的1．26％（12／949）。12例中，男性6例，女性6例，年龄为26～65岁。平均48岁。术中所见：单发腺癌8例，多发4例；合并结石1例。位于胆囊体部8例，底部4例；广基7例，带蒂5例。病理：管状腺瘤5例，乳头状腺癌4例。管状乳头状腺癌3例。其中癌变2例，重度异型增生1例。3例应用免疫组化检测癌胚抗原CEA，结果均为阳性。其中1例为腺瘤癌…     

胆囊隆起样病变临床分析

目的本文对我院21例经手术及病理证实的胆囊隆起样病变进行了临床与声象特点分析.方法男8例,女13例,年龄分布25岁～69岁,平均为28.9岁±3.5岁,经B超检查发现19例占90.5%(19/21),经CT检查发现2例占9.5%(2/21),B超及CT检查前常规禁食水8h～12h,CT检查前14h最好口服碘番酸0.5g～1g.结果21例术前经B超及CT检查诊断为胆囊内隆起样病变,女性多于男性,年龄以30岁～50岁为多占76.1%(16/21).息肉发生的数目本组多发性息肉占52.38%(11/21),单发性占47.62%(10/21).病理分类胆固醇息肉61.90%(13/21),腺瘤样息肉占19.05%(4/21),炎性息肉14.29%(3/21),腺瘤恶变4.76%(1/21),同时合并胆囊结石占23.80%(5/21).结论不论息肉大小若伴有胆石或胆道症状者也以手术为佳.     

胆囊切除与结直肠息肉相关性的研究

背景：胆囊切除已被认为是结直肠癌的危险因素之一,但胆囊切除与结直肠息肉的关系一直未受到重视。目的：探讨胆囊切除与结直肠息肉的相关性。方法：连续收集经结肠镜排除恶性肿瘤、炎症性肠病、家族性腺瘤性息肉病等疾病的患者425例,根据既往有无胆囊切除史分为胆囊切除组（n=63）和对照组（n=362）,对两组患者结直肠息肉的发生率、内镜下息肉表现和组织学类型进行分析。结果：胆囊切除组结直肠息肉发生率高于对照组（46.0%对37.8%）,但差异无统计学意义（P=0.219）。两组患者息肉的部位和形态均无明显差异（P=0.753,P=0.127）;但胆囊切除患者腺瘤性息肉的发生危险显著高于对照组（OR=1.79,P=0.006）。亚组分析示胆囊切除史≥10年的结直肠息肉发生率与胆囊切除史〈10年无明显差异（P=0.11）。结论：胆囊切除并未增加结直肠息肉发生的危险性,但腺瘤性息肉的发生率显著增高,因此对胆囊切除患者应重视早期结直肠癌和腺瘤性息肉的筛查。     

彩色多普勒超声在胆囊腺瘤与胆囊癌鉴别诊断中的临床价值

目的探讨彩色多普勒超声在胆囊腺瘤与胆囊癌鉴别诊断中的临床价值。方法选取我院2013年1月至2016年12月经病理证实为胆囊腺瘤(95例)和胆囊癌(100例)的患者进行临床研究,所有患者均经彩色多普勒超声诊断,分析比较胆囊腺瘤与胆囊癌各项指标的差异。结果 95例胆囊腺瘤患者中合并胆囊腔内结石18例(18.95%),合并壁内结石13例(13.68%);胆囊浆膜层均显示完整(95/95);CDFI在胆囊腺瘤增厚囊壁内未测及明显血流信号共89例(93.68%),仅6例测及少量星点状血流信号。100例胆囊癌患者中合并腔内结石20例(20.00%),无1例合并壁内结石,胆囊浆膜层显示不完整57例(57.00%),CDFI在胆囊癌肿块内测及丰富血流信号者共82例(82.00%),形态呈"网篮样"改变;胆囊癌体积、最大血流速度均大于胆囊腺瘤,差异具有统计学意义(P0.001)。结论彩色多普勒超声对胆囊腺瘤与胆囊癌具有较高的鉴别诊断价值。     

大肠息肉与大肠癌的演变关系（附494例分析）

本组息肉患者４９４例，癌变者１０１例，随着息肉的增大，其癌变率也增加。恶变息肉主要分布在直肠（５７．４％），次为乙状结肠（１９．８％）。管状腺瘤瘤体较小，恶变率较低，绒毛型腺瘤瘤体较大，恶变率较高，且呈重度不典型增生多见。单发息肉癌变率１３．１％，２－５个息肉者癌变率２４．４％，６个以上者癌变率３８．０％，腺瘤病１２例全部癌变。息肉癌变时间１至１５年。癌变术后标本病理均见癌旁组织残存良性管状腺瘤或绒毛型腺瘤成份，从组织学上证明了息肉癌变过程。     

保留灌肠治疗溃疡性结肠炎疗效观察

[目的]观察10%鸦胆子乳联合地塞米松保留灌肠治疗溃疡性结肠炎的临床疗效.[方法]10%鸦胆子乳50 ml加地塞米松5 mg混合充分摇匀,用18～20号肛管每晚经肛门插入保留灌肠2 h,1个月为1个疗程.如未治愈可进行第2个疗程治疗.疗程结束后均经结肠镜复查.[结果]48例患者经1个疗程治愈38例(78.5%),其中轻度32例,中度6例;好转10例(21.5%),其中中度6例,重度4例.伴腺瘤息肉2例,炎性息肉5例.1例腺瘤息肉经2个疗程灌肠治疗,腺瘤脱落,另1例腺瘤息肉者行肛肠科手术;5例炎性息肉经治疗均消失.其余病例均获临床治愈,其治愈率为97.5%.[结论]该疗效理想而可靠,简便易行,值得临床尝试和推广.     

转化生长因子-β1、Smad3、Smad4和Smad7在结直肠癌发生中的作用

结直肠腺瘤-腺癌序列是目前公认的结直肠癌发生学说，但关于结直肠腺瘤，特别是高危型结直肠腺瘤中转化生长因子（TGF）-β1通路蛋白表达的临床研究较少。目的：探讨TGF—β1、Smad3、Smad4和Smad7在结直肠癌发生中的作用。方法：选取2000年8月-2006年12月六安市人民医院结直肠息肉标本110例（包括腺瘤性和非腺瘤性息肉）、结直肠癌40例和正常结直肠组织20例，以免疫组化染色检测TGF—β1、Smad3、Smad4和Smad7在各组中的表达．并分析高危型腺瘤中TGF-IM、Smad3、Smad4和Smad7表达与临床病理特征的关系。结果：TGF-IM、Smad3、Smad4、Smad7在息肉组、结直肠癌组和对照组中的表达有显著差异（P〈0．05），其表达与高危型腺瘤患者的临床病理特征均不相关。高危型腺瘤和DukesA期结直肠癌中TGF-IM、Smad3、Smad7的表达有显著差异（P〈0．05），而Smad4表达无显著差异。结论：TGF—β1通路可能参与了结直肠癌的发生过程，TGF—β1、Smad3和Smad7可能在结直肠腺瘤的癌变早期起作用。     

Percutaneous transhepatic biliary endoscopic procedures

Two cases are presented to demonstrate the acceptability of the percutaneous route for performing endoscopic procedures in the biliary tree. They involved debridement of an atypical villoglandular polyp and ultrasonic lithotripsy of intrahepatic stones. Both cases serve to introduce percutaneous biliary endoscopy as a viable alternative for diagnosis and therapy in selected cases.     

Accuracy of pathologic interpretation of colorectal polyps by general pathologists in community practice.

BACKGROUND: The histologic features of colorectal polyps often guide colonoscopic surveillance and the need for surgical intervention. Our objective was to evaluate the pathologic interpretation of colorectal polyps by general pathologists in community practice. METHODS: Twenty histologic slides of colorectal polyps were reviewed by 20 randomly selected general pathologists in community practice. There were 5 malignant polyps, 9 adenomas, and 6 miscellaneous polyps. RESULTS: Cancer was correctly identified in 91% of readings and adenoma in 94%. The grade of differentiation of cancer was provided in 55% of readings, and comment regarding whether the resection margin was free of cancer was made by 50% of pathologists. Tubular adenoma was called tubulovillous or villous in 35% of readings, but tubulovillous or villous adenoma was seldom (2%) called tubular. High-grade dysplasia was correctly identified in 47% of 60 readings, was called invasive cancer in 22%, and was missed in 31%. Among miscellaneous polyps, hyperplastic polyp was correctly recognized in 75% of cases, and inflammatory polyp and juvenile polyp each were recognized by 16 of 20 pathologists (80%). Peutz-Jeghers hamartoma was identified by 4 of 20 pathologists (20%), and the polypoid phase of solitary rectal ulcer syndrome was recognized by 2 pathologists (10%). CONCLUSION: Areas of strength with regard to interpretation of colon polyps by general pathologists in community practice included identification of cancer, adenoma, and certain non-neoplastic polyps (e.g., inflammatory and juvenile polyps). Areas of weakness included lack of comment on cancer differentiation and proximity to the resection line, erroneous identification of high-grade dysplasia, and identification of rare lesions. The results of this study suggest areas on which to focus continuing education and continuous quality improvement efforts with regard to polyp interpretation.     

氩离子凝固器内镜下治疗的探讨

目的 通过对52例不同消化道疾病的内镜下氩离子凝固术（APC）治疗结果的回顾分析，评估其疗效及安全性。方法 2001年4月对2002年5月对52例门诊及住院患者因各种原因行内镜检查所发现的病变予以内镜下APC治疗，其中消化道出血者29例行止血治疗，消化道息肉样病变23例行APC切除治疗。结果 出血性溃疡中有1例因动脉性喷血而治疗失败转手术，其余均1次治疗成功，止血率达96．5％；对于小于5mm的息肉仅用APC凝固即可清除，大息肉或腺瘤则需先行圈套器切除后再用APC处理残端组织，效果满意且用EndoCut高频电刀切除大的宽基腺瘤安全可靠。本组仅1例出现无症状的局部粘膜下气泡。结论 APC对于大多数大门脉高压性的消化道出血止血效果满意，但对较大口径的动脉性出血则有疑问。APC结合智能电刀处理各种消化道息肉样病变安全可靠。     

Risk of colorectal adenoma in liver transplant recipients compared to immunocompetent control population undergoing routine screening colonoscopy

BACKGROUND: Immunosuppression following solid organ transplantation has been associated with a higher prevalence of cancers including colon cancer. However, the risk of colorectal adenoma following liver transplantation is unknown. The objective of this pilot study is to determine whether the prevalence of colorectal adenoma is increased in liver transplant recipients. METHODS: In this retrospective study, 25 patients who had liver transplantation at our institution between 1994 to 1997 and who underwent routine posttransplantation colonoscopy were compared with 50 controls who were undergoing routine screening colonoscopy. Transplant recipients who were younger than 45 years, survived less than 3 years following liver transplant, with history of inflammatory bowel disease, or prior history of colonic adenoma or cancer were excluded from the study. In both groups, colonoscopic diagnosis of polyp was confirmed by pathologic diagnosis of adenoma on biopsy. RESULTS: 25 (12M/13F, mean age 53 +/- 7 years) liver transplant recipients were compared with 50 controls (19M/31F, mean age of 59 +/- 7 years). In transplant recipients, colonoscopy was performed 41 +/- 19 months after liver transplantation. Seven (28%) liver transplant recipients (5M, 2F) and 4 (8%) controls (3F, 1M) were found to have adenomatous polyp (OR 4.5, 95% CI 1-21.2, P = 0.049). Malignant polyps were not detected in both groups. CONCLUSION: Liver transplant recipients appear to have an increased risk for developing colorectal adenoma. Early screening colonoscopy is warranted for this group of patients.     

Early sigmoid colon carcinoma developed from a pedunculated polyp

A 60‐year‐old man underwent routine colonoscopy, and was noted to have a pedunculated polyp in the sigmoid colon. The pathologic diagnosis was adenoma, and due to patient’s personal circumstances, the lesion was left untreated. The colonoscopic examination was repeated 4 years and 11 months later, to find that the polyp had transformed into an elevated lesion with irregularly depressed surface. The patient was diagnosed as having early sigmoid cancer, and underwent sigmoidectomy. The histologic examination of the excised specimen revealed well‐differentiated adenocarcinoma with invasion into the submucosal layer. Through studying the natural course of colon cancer, it has become known that the advanced cancers commonly develop from polyps with short pedicles (sessile polyps). This case represents an early sigmoid cancer developed from a pedunculated polyp, which differs from the current mainstream concept of ‘polyp‐cancer sequence of colon cancer.’     

代谢综合征对结直肠管状绒毛状腺瘤的影响因素分析

目的分析结直肠管状绒毛状腺瘤与代谢综合征的关系。 方法收集2017年6月至2020年12月南方医科大学附属惠阳医院经手术病理确诊的271例患者。其中管状腺瘤患者203例，管状绒毛状腺瘤患者68例。比较结直肠管状腺瘤与管状绒毛状腺瘤患者纤维结肠内镜检查的基本情况，结直肠息肉一般特征、数目、病理，以及代谢综合征相关指标水平等。采用Logistic多因素回归分析山田分型、最大息肉直径、代谢综合征相关指标与结直肠管状绒毛状腺瘤的关系。 结果累计息肉数目最多部位、最大息肉好发部位、病理为管状绒毛状腺瘤/管状腺瘤好发部位均为乙状结肠。结直肠管状腺瘤与管状绒毛状腺瘤患者山田分型、最大息肉直径、血清甘油三酯水平差异均有统计学意义（P均<0.01），而高血压、脂肪肝、空腹血糖受损或糖尿病情况及总胆固醇水平、血清尿酸水平、癌胚抗原水平差异均无统计学意义（P>0.05）。Logistic多因素回归分析结果显示，山田分型及最大息肉直径与结直肠管状绒毛状腺瘤有关联[Wald χ²=5.756，Exp（B）=2.494，P=0.016；Wald χ²=23.173，Exp（B）=12.842，P<0.001]，而血清甘油三酯水平与结直肠管状绒毛状腺瘤无关联。 结论与结直肠管状腺瘤患者相比，代谢综合征与结直肠管状绒毛状腺瘤发病并无直接关联，但息肉直径大小及山田分型与结直肠管状绒毛状腺瘤发病有关联。     

LARGE HYPERPLASTIC POLYP DEVELOPING AFTER ENDOSCOPIC MUCOSAL RESECTION OF GASTRIC ADENOMA IN A PATIENT RECEIVING IMMUNOSUPPRESSIVE THERAPY

A 59‐year‐old man underwent endoscopic mucosal resection (EMR) for gastric adenoma. He had suffered from end‐stage renal disease for several years and had received renal transplantation some 5 months before EMR. Subsequently, he took immunosuppressive agents. Follow‐up gastrofiberscopy 6 months after EMR showed a sessile polyp at the resection site twice as large as the original adenoma; biopsy specimens revealed a hyperplastic nature. At the time of writing, this hyperplastic polyp has neither increased in size nor developed adenomatous or carcinomatous changes by histological examinations over the past 5 years. Therefore, this is a case of hyperplastic polyp occurring at the gastric adenoma resection site, and suggests the possible effect of immunosuppressive therapy on the post‐EMR healing process and hyperplastic polyp development.