放大色素内镜在消化道疾病诊断中应用的研究进展

放大色素内镜技术（magnifying chromoendoscopy，MCE）是将具有放大功能的内镜和黏膜染色相结合的一种检查方法。随着内镜的普及及其检查技术水平的提高，以及各种新型内镜器械的开发进步，MCE在临床上的应用也越来越广泛，在发现微小病变，区别良恶性肿瘤，鉴别黏膜和黏膜下病变，了解黏膜有无萎缩及程度，指导黏膜活检等方面都有十分重要意义，进一步提高了内镜对疾病的诊断水平。[第一段]     

放大内镜结合黏膜染色技术诊断溃疡性结肠炎--附116例放大内镜形态分析

溃疡性结肠炎的诊断主要根据结肠镜的检查结果，由于溃疡性结肠炎的黏膜病变及溃疡形态复杂多样，黏膜活检的炎症病变缺乏特异表现，部分病例在内镜下与克隆病、肠结核、淋巴瘤及其它肠道溃疡性病变难以鉴别。放大内镜技术可将黏膜结构放大30～100倍，能有效地发现黏膜的微细病变及病变形态的特征和差异，对降起性病变可根据黏膜表面的pit形态特征作出与病理高度一致的诊断，     

窄带成像系统在结肠镜检查中的应用

结肠镜检查目前广泛应用于下消化道疾病的诊断，不仅能直接观察结，直肠病变，还能活检病变进行病理学诊断，开展各种内镜下的微创治疗。随着内镜技术的提高和染色内镜、放大内镜的普及，大部分结、直肠病变都能及早发现。近年来开发的窄带成像（narrow-band imaging,NBI）系统被认为能提高消化道黏膜表面结构的观察水平。     

消化道肿瘤内镜微创治疗新进展

发现与切除消化道肿瘤是内镜医师关注的焦点之一.内镜下消化道肿瘤治疗技术主要为病变组织切除术和病变组织破坏术.病变组织切除术主要包括内镜黏膜切除术(endoscopic mucosal resection,EMR),内镜黏膜下剥离术(endoscopic submucosa dissection,ESD)等;病变组织破坏术主要包括激光治疗、微波治疗、光动力学治疗、氩离子凝固法等.目前,国内外均以EMR和ESD技术作为消化道肿瘤内镜治疗的标准方法.我们在此总结EMR和ESD技术以及以这2项技术为基础的内镜微创治疗在消化道肿瘤中的发展与应用.     

内镜超声指导食管黏膜下肿瘤的黏膜切除术

目的探讨内镜超声指导食管黏膜下肿瘤黏膜切除术的有效性和安全性。方法对1992年至2005年间656例疑为上消化道黏膜下肿瘤患者进行内镜超声检查，其中97例食管病变内镜超声显示病变来源于黏膜肌层，有43例经知情同意后行内镜下黏膜切除术。切除病变经过病理检查明确病变的层次和病变性质。结果通过与病理结果对照表明，EUS准确地判断肿瘤所在的层次；通过黏膜切除术切除所有病变，无一例发生并发症。结论内镜超声检查能准确判断黏膜肌层来源的肿瘤，可用于指导黏膜切除术。     

内镜全层切除术的研究进展

早期消化道肿瘤内镜治疗技术主要为病变组织切除术和病变组织破坏术。病变组织切除术目前主要包括内镜黏膜切除术（endoscopicmucosalresection,EMR）、内镜黏膜下剥离术（endoscopicsubmucosadissection,ESD）和内镜黏膜下挖除术（endoscopicsubmueosalexcavation,ESE）等;病变组织破坏术主要包括激光治疗、微波治疗、光动力学治疗、氩离子凝固法等。目前,国内外均以EMR和ESD技术作为早期消化道肿瘤的标准内镜治疗方法。     

应重视肠道疾病临床诊疗中新技术的应用

肠道疾病虽然病变种类繁多,但临床上主要表现为黏膜病变。随着黏膜染色和放大内镜技术、内镜下黏膜剥离活检及黏膜切除、超声内镜、双气囊小肠镜、胶囊内镜以及精细影像学技术的开展,使肠道黏膜一些早期病变得以及时诊断和治疗,促进了临床肠道疾病诊疗水平的提高。但目前这些新技术尚不为多数人所熟悉,为此将其各自的特点总结如下。     

内镜下诊治大肠早期癌的进展

近年来随着内镜诊断和治疗技术提高，尤其色素内镜、放大内镜、超声内镜、宽带成像内镜和内镜下黏膜切除术（EMR）、内镜下黏膜下层剥离术（ESD）等技术应用，在日本发现许多小于1cm甚至0．5cm内小的或微小癌的病灶，在内镜下表现为单纯平坦Ⅱb或单纯凹陷Ⅱc的表现，在病理上表现为denovo即没有腺瘤病变的早期癌肿，这对大肠癌的发生学上提出了一个耘的概念，作为消化及消化内镜的医务工作者提出新的课题，故很有必要对其进一步探讨。     

高分辨率扩大内镜诊断上消化道病变

内镜下胃肠道病灶的发现依赖肉眼对黏膜病变的辨认，然而最终诊断却通常由活检组织的病理学研究作出。尽管由黏膜表面的内镜特征诊断病变已成为可能，但活检作为一种确诊病灶(癌肿、腺瘤、增生或化生)的手段依然非常重要。     

超声内镜联合染色内镜在早期食管癌诊断中的应用价值

目的:分析超声内镜联合染色内镜技术诊断早期食管癌的准确性,评价其临床应用价值.方法:2009-08/2011-09行普通白光内镜(WLE)检查发现食管黏膜可疑病变67例,患者72处病灶纳入研究,可疑病变包括食管黏膜粗糙、糜烂、颜色异常、微隆起等.所有病变行活组织病理检查,分析超声内镜联合染色内镜诊断早期食管癌的准确性.结果:72处局灶性病变中,病理组织学证实癌性病变16处(9处病变行内镜下黏膜切除术或内镜黏膜下剥离术治疗,7处病变行手术治疗).非癌性病变56处,为慢性炎症、轻-中度不典型增生.WLE诊断早期食管癌的敏感度、特异度和准确性分别为:81.3%、66%、62.5%;超声内镜联合染色内镜对应值分别为:87.5%、98.2%、95.8%.结论:超声内镜联合染色内镜对食管病变有较高的诊断价值,尤其是对诊断早期食管癌及癌前病变有重要意义.     

上消化道胶囊内镜发展与创新北大核心CSCD

上消化道疾病高发,传统插管式胃镜是检查上消化道疾病最常用的检查方法和"金标准"。为了更舒适无创的检查上消化道黏膜,多项研究提出了上消化道胶囊内镜的概念,但是由于上消化道各部位解剖与生理结构的差异,目前可以使用的胶囊内镜如单纯被动式、磁控式、线控式、磁控联合线控式以及侧视胶囊内镜都存在一定的局限性,无法实现对上消化道整体黏膜情况的观察。文章试图通过介绍适用于食管、胃以及十二指肠检测的胶囊内镜,分析各内镜的诊断效能及其不足,探讨未来上消化道胶囊内镜可能的发展方向。     

Endoscopy in the diagnosis of tumours of the digestive tract

Methods of digestive endoscopy belong to the diagnostic standard of tumours of the digestive tract. The classical method is endoscopic examination of the upper and lower part of the tract which makes it possible to identify under visual control lesions which alter the character of the mucosal structure of hollow organs or lead to changes e.g. of the coloration of portions of the mucosa. From these sites samples can be taken to evaluate the character of the lesion and facilitate the differential diagnosis. Similarly examination of the pancreatobiliary system (ERCP) evaluates gross changes in the morphology of efferent systems. The objective is to find diagnostic methods which detect early stages of the disease, i.e. so-called minimal changes in the architectonics or biochemical structure at the level of the examined mucosa. These methods include endocopic sonography, supplemented by aimed biopsy. The examination makes it possible to visualize individual layers of the wall e.g. of the oesophagus, stomach or gut. An irregular pattern of the layers is the sign of a process which takes place inside the wall. New methods which make the diagnosis of mucosal lesions more accurate are endoscopic autofluorescence and optic coherent tomography (OCT). In particular OCT seems to be a promising contribution to the diagnosis of dysplasias and early tumourous changes of the oesophagus, stomach and gut.     

AIDS病人消化道黏膜病变内镜及病理特征研究

目的研究艾滋病(AIDS)病人消化道黏膜病变的内镜及病理特征。方法对北京地坛医院1995-2009年期间收治的AIDS病人中,经临床、内镜、病理确诊并发食道、肠道黏膜病变的62例病例资料做回顾性分析。结果 62例中,31例食道黏膜病变病人胃镜像显示不同程度的黏膜弥漫性充血、水肿,点片状白斑、白色伪膜或条索样、絮状真菌团块(6例并发食管黏膜溃疡)。其中16例病人病理检测到真菌菌丝或孢子而被确诊真菌性食管炎。33例肠道黏膜病变病人(2例同时合并食道黏膜病变)结肠镜像显示,除2例黏膜未见明显异常外,余31例均有结肠黏膜病变。慢性结肠炎14例,慢性结肠炎伴结肠溃疡15例,阿米巴性溃疡和回盲部恶性淋巴瘤(非霍奇金淋巴瘤)各1例。病理学特点:急慢性食管、结肠炎,主要表现为黏膜组织疏松水肿,伴炎性细胞浸润,而溃疡除炎性病理改变外,伴有黏膜局灶、片状坏死,中性粒细胞浸润,呈非特异性炎症改变。结论 AIDS病人合并消化道黏膜病变肠道溃疡的发生率要高于食道。肠道黏膜病变以慢性结肠炎和结肠溃疡为主,同时可并发恶性肿瘤。     

微探头共聚焦显微内镜诊断胃黏膜病变的初步应用

目的:探讨Cellvizio微探头式共聚焦内镜诊断胃黏膜病变的能力。方法:收集门诊6例胃黏膜病变患者行Cellvizio微探头式共聚焦内镜检查术。检查中静脉注射荧光素钠作为荧光剂。每例患者均经内镜直视诊断、共聚焦微探头诊断并获取靶向活组织行病理检查。符合手术指征者行外科手术。结果:6例患者共7处病灶,其中息肉2处,黏膜粗糙、发红2处,浅表凹陷灶1处,隆起伴凹陷灶1处,深溃疡1处。所有患者均完成共聚焦内镜检查,共获得连续视频图像32段。微探头共聚焦内镜易于操作其诊断正确者为6例(6/7),未发生明显不良反应。结论:Cellvizio微探头式共聚焦内镜操作简便,即时成像,是有效的胃黏膜病变诊断手段。     

Chronic beta-carotene supplementation does not alter the gastric mucosal response to acute aspirin ingestion

Carotenoids and retinoids have been reported to reduce gastrointestinal mucosa damage from a variety of irritants. We performed double-blind, placebo-controlled endoscopic trial to evaluate the effect of chronic beta-carotene supplementation upon the gastric mucosal response to acute aspirin injury. Six subjects taking chronic beta-carotene and six taking placebo each ingested 650 mg of aspirin after an endoscopy confirmed normal gastric mucosa. Three hours later, mucosal lesions were counted at repeat endoscopy. beta-Carotene did not prevent acute mucosal injury better than placebo.     

Miniprobe sonography in the evaluation of 169 patients with gastrointestinal disease

OBJECTIVE : It is still difficult to precisely differentiate elevated lesions of the gastrointestinal mucosa or estimate the depth of malignant lesions by using conventional endoscopy and biopsy. The aim of the present study was to assess the clinical value of miniprobe sonography (MPS). METHODS : A total of 169 patients (including 83 patients who underwent endoscopic treatment or surgery) with gastrointestinal disease were examined by using MPS in conjunction with endoscopic examination. The diagnosis according to MPS was compared with macroscopic findings, endoscopic biopsy and surgical results. RESULTS : In the case of elevated lesions of the gastrointestinal mucosa with negative biopsies, compared with surgical findings, the diagnostic accuracy of MPS was 98.3% (115/117). In the case of malignant lesions, MPS findings with regard to the lesion depth were 100% in agreement with those from surgical biopsy (31/31). CONCLUSION : The MPS technique is significantly superior to conventional endoscopy with pathological biopsy in the differentiation of elevated lesions of the gastrointestinal mucosa and thus has important clinical value. But in the case of malignant lesions, only the depth of infiltration into the gastrointestinal wall can be correctly assessed by MPS, so its value is limited in the identification of lymph nodes and distal metastases.     

How to Catch a Suspicious Bleeding Site in Flagrante

Background

In search for a source of gastrointestinal bleeding, endoscopy frequently reveals mucosal lesions of questionable dignity.

Aim

To investigate the probability of ascertaining conclusive evidence for gastrointestinal bleeding from a suspicious mucosal lesion through a single or multiple consecutive endoscopies.

Methods

A mathematical model is developed to estimate the probability of successful diagnosis of a bleeding gastrointestinal lesion associated with single or multiple endoscopies.

Results

The probability of a successful confirmation through endoscopy depends on the length of time that signs of recent bleed persist at the site of the mucosal lesion and on the number of repeat endoscopies that one is willing to invest in confirmation. Assuming persistence of endoscopic evidence for 6-12 hours after the initial bleeding, a single endoscopy is associated with a 22 %–38 % chance of observing a suspicious site with clear evidence of bleeding. Using potentially up to 2 additional repeat endoscopies can raise such chances to 52 %–76 %.

Conclusion

The rates of success may provide useful guidance in scheduling endoscopies for the work-up of gastrointestinal bleeding and decision making about the utility of repeat endoscopy in instances of suspicious but inconclusive mucosal lesions.     

MAGNIFICATION ENDOSCOPIC VIEW OF AN EARLY GASTRIC CANCER USING ACETIC ACID AND NARROW‐BAND IMAGING SYSTEM

A 62‐year‐old woman was referred to Mie University Hospital, Tsu, Japan, for examination of upper gastrointestinal tract. The conventional endoscopy showed a slightly depressed lesion on the greater curvature at the gastric body. The surface of surrounding non‐neoplastic mucosa using magnification endoscopy with acetic acid was gyrus‐villous pattern whereas the surface of the lesion was rough. Furthermore, magnification endoscopy using acetic acid and narrow‐band imaging system visualized clearer fine surface pattern of carcinoma. The lesion had a rough mucosa with irregularly arranged small pits. The lesion was resected completely by endoscopic mucosal resection with insulated‐tip electrosurgical knife. Narrow‐band imaging system with acetic acid may be able to visualize not only the capillary pattern but also the fine surface pattern of gastric carcinoma.     

Technology insight: endoscopic submucosal dissection of gastrointestinal neoplasms

Gastrointestinal neoplasms can be cured by local resection as long as the lesions are in the early stage and have not metastasized. Endoscopic resection is a minimally invasive treatment for early-stage gastrointestinal neoplasms, and endoscopic submucosal dissection (ESD) is one type of endoscopic resection that has been developed in the past 10 years. For ESD to be a reliable, curative treatment for gastrointestinal neoplasms, it is necessary for the endoscopist to detect the lesion early, make a precise pretreatment diagnosis, ensure that the patient has the correct indication for endoscopic resection, and have the skill to perform ESD. For early lesion detection, endoscopists should pay attention to subtle changes in the surface structure, the color of the mucosa and the visibility of underlying submucosal vessels. Chromoendoscopy and magnifying endoscopy are useful for determining the margin of the lesions for pretreatment diagnosis, and endoscopic ultrasonography and magnifying endoscopy are useful for determining the depth of invasion. For ESD to be successful, local injection of sodium hyaluronate helps maintain mucosal elevation during dissection. Selecting the appropriate knife, using transparent hoods wisely, employing a good strategy that uses gravity, and having good control of bleeding are all needed to make ESD reliable.     

内镜黏膜下剥离术治疗上消化道病灶的初步评价

目的 探讨内镜下黏膜剥离术(ESD)处理上消化道病灶的疗效和安全性.方法 以胃镜检查发现的上消化道黏膜病灶及黏膜下病灶作为入选对象,通过超声内镜和(或)活检病理检查明确病灶大小、位置、范围、性质,应用钩刀、IT刀、氩气刀及高频电凝电切术进行ESD操作,步骤包括:(1)胃镜及黏膜染色确定病灶,针刀或者氩气刀标记病灶;(2)黏膜下注射含靛胭脂及肾上腺素生理盐水抬高病变;(3)预切开病变周围黏膜一圈;(4)自病变黏膜下层完整剥离病灶.术后应用抑酸、黏膜保护剂治疗,术后第1、2、6个月内镜随访,评价溃疡是否愈合以及病灶有无残留与复发.结果 2006年8月至2008年1月,共153例患者进入观察研究.黏膜病变85例(溃疡型病灶2例,隆起型病灶48例,糜烂型病灶35例),病灶直径0.4～5.0 cm,平均2.0 cm;手术时间15～210 min.平均55min.所有病例均切除病灶,其中1例迟发性出血行内镜下紧急止血,7例穿孔均保守治疗愈合.随访期溃疡创面均愈合,其中4例复发,3例再次ESD完整切除病灶,1例手术切除.黏膜下肿瘤68例,52例术前行超声内镜检查,其余病例经术后病理证实.病灶直径0.4～4.0 cm,平均1.2 cm;手术时间10～182 min,平均41 min;68例完整剥离黏膜下肿瘤,1例改行尼龙绳结扎治疗.1 1例穿孔均保守治疗,1例术后出血未控制行手术治疗.结论 ESD作为一种微创治疗方法,能实现较大病变的一次性大块剥离,剥离的病变能提供完整的病理诊断资料,病变局部的复发率低,并发症少,为上消化道黏膜层病灶尤其是早期肿瘤以及黏膜下肿瘤的治疗开辟了新的途径.