[基础医学]内镜在消化系疾病诊治中的应用课件

書式設定, 書式設定,第 2 ,第 3 ,第 4 ,第 5 ,*,基础医学内镜在消化系疾病诊治中的应用,基础医学内镜在消化系疾病诊治中的应用,1,内镜在消化系疾病诊治中的应用,内镜在消化系疾病诊治中的应用,2,内镜发展史,1806-,硬式内镜,-,德国法兰克福，,Bozzin,1957-,纤维内镜,-,美国医生，,Hirschowitz,1983-,电子胃镜,-,美国，,Welch Allyn,公司,-,电视监视器,内镜发展史1806-硬式内镜,3,Chromoendoscopy,Magnifying endoscopy,IPCL,NBI, AFI,EMR,ESD,ERCP,E,US,NOTES,Chromoendoscopy,4,Esophageal anatomy,Ce:,cervical,esophagus,e,Ut:,upper thoracic esophagus,Mt:,middle thoracic,esophagus,Lt:,lower thoracic esophagus,Ae:A,bdominal,esophagus,Esophageal anatomy Ce: cervic,5,Epithelium,Lamina prop.,Ma,scularis,mucosae,Submucosa,Prop. muscle,Serosa,m1,m2,m3,sm1,sm2,sm3,Depth of tumor invasion,EpitheliumLamina prop.Mascular,6,正常食管组织病理,Epithelium,Lamina propria,Muscularis mucosae,C,ircular muscle,Longitudinal,muscle,Submucosa,Serosa,正常食管组织病理EpitheliumLamina propr,7,Epidemiology of the esophageal cancer,Carcinoma of the esophagus incidence,North china,130,/,100,000,population,America,5,/,100,000,population,Japan,5,/,100,000,population,Epidemiology of the esophageal,8,Urban China,Rural China,United States,United Kingdom,Switzerland,52.4,(2001),0,5,10,15,20,25,30,35,40,45,50,55,31.3,(2000),24.9,(1999),27.5,(1999),5.6,(1999),14.7,(1999),8.1,(1998),17.2,(1999),11.6,(1999),12.7,(1999),8.0,(1999),10.0,(1999),37.0,(2000),11.0,(1997),23.7,(1999),Mortality per 100,000 males,Japan,Korea,Italy,Canada,Germany,France,Sweden,Australia,Russia,Argentina,Country,Hatakeyama et al. nature reviews cnacer 2004 Sep;4(9):688-94,Urban ChinaRural ChinaUnited S,9,食管癌的,病理,(,病変部位,),日本,Mt: 51.5%,Lt: 22.6%,Ut: 13.7%,中国,Mt:52.9-63.33%,Lt:24.95-38.92%,Ut:2.80-14.10%,食管癌的病理 日本中国,10,0,type (,superficial type,),I,type,:,superficial and protruded type,(,1mm),II,type,:,superficial and flat type,IIa:,slightly elevated type,(1mm),IIb:,flat type,IIc:,slightly depressed type,(0.5mm),Classification of early esophageal cancer,0 type (superficial type) Cla,11,advanced type,1,type:,protruding type,2,type:,ulcerative and localized type,3,type:,ulcerative and infiltrating type,4,type:,diffusely infiltrating type,5,type:,unclassifiable type,Classification of advanced,esophageal cancer,advanced type Classification o,12,表浅型食管癌的肉眼分类,0-I,0-II,0-III,Ip,Ip1,Isep,IIb,IIc,IIa,III,polypoid type,plateau type,predominantly subepithelial type,slightly elevated type,flat type,slightly depressed type,superficial and distinctly depressed type,表浅型食管癌的肉眼分类 0-I0-II0-IIIIpIp1,13,组织学分类,鳞状细胞癌,(90%),腺癌,:(1),单纯腺癌,(2),腺鳞癌,(3),粘液表皮样癌,(4),腺样囊性癌,其他,:,未分化癌和癌肉瘤,组织学分类鳞状细胞癌(90%),14,食管癌的,TNM,分期（,AJCC,，,1997,）,食管癌的TNM分期（AJCC，1997）,15,T,分期,Tis,原位癌,T1,累及粘膜下层,T2,累及固有肌层,T3,累及外膜及食管旁组织,T4,累及临近组织器官,T分期Tis 原位癌,16,ERCP, Choledochoscopy,ERCP, Choledochoscopy,17,CT, ERCP, EST, ENBD,Endoscopic sphincterotomy,CT, ERCP, EST, ENBD,18,Diagnosis,Diagnosis,19,1)50,岁以上的男性,2),多饮,吸烟,3),头颈部癌或其他脏器的癌,4),食管癌的家族史,5),腐蚀性食管炎,6),贲门失弛缓症,7)Barrett,食管,H,igh risk group,of the esophageal cancer,1)50岁以上的男性 High risk group o,20,pronase,(,pH78,),500mg,NaHCO,3,1,g,dimethylpolysiloxane10 100mg,water,100ml,前处理液,(,检查前,5,分,服用,),床上改变体位,pronase(pH78) 500mg前处,21,色素内镜检查分类,色素散布法,-,色素潴留,-,靛胭脂,染色法,-,色素浸润吸收,-,亚甲蓝、甲苯胺蓝,色素反应法,-,特异反应,-,刚果红、卢格氏液,荧光内镜检查,-,荧光,-,少用,色素内镜检查分类色素散布法-色素潴留,22,2%,Tolonium chloride,1.5,Strong iodine solution,I,1.5g,KI,3,g,H,2,O 100ml,色素,2% Tolonium chloride色素,23,Chromoendoscopy,基础医学内镜在消化系疾病诊治中的应用课件,24,Tolonium chloride,2,t,olonium chloride,2,3ml,喷洒,立即用水冲洗后观察,Tolonium chloride 2 toloniu,25,Strong iodine solution,1-3%,碘液,Strong iodine solution 1-3%,26,碘,染色,1.5,碘液,10,20ml,散布,1,2,分,钟后吸引碘液,用,40,60ml,水冲洗,再用,10,20ml,碘液重复染色,碘染色1.5碘液1020ml散布,27,副作用的处理,I,2,+2Na,2,S,2,O,3,=2NaI+Na,S,4,O,6,2.5,硫代硫酸钠,10,20ml,、,食管内,散布,副作用的处理I2+2Na2S2O3=2NaI+NaS4O6,28,Tolonium chloride,Strong iodine solution,Tolonium chlorideStrong iodin,29,基础医学内镜在消化系疾病诊治中的应用课件,30,Host Cell,Higashi, et al. Science 2002, Mimuro et al. Mol Cell 2002,Grb2,SOS,Ras,Raf,EPIYA Repeat region is important,SHP-2,Hummingbird cell,Non-phosphorylation,phosphorylation,cag,PAI,PO4,ERK pathway,Abnormal Cell growth,Actin Polymerization etc.,CagA,H.pylori,CagA,Host CellHigashi, et al. Scien,31,Electronmicroscope,Helicobacter pylori,ElectronmicroscopeHelicobacter,32,2005,年诺贝尔奖获得者,生理学或医学奖授予澳大利亚科学家巴里,马歇尔和罗宾,沃伦，以表彰他们发现了导致胃炎和胃溃疡的细菌,幽门螺旋杆菌（,HP,）,2005年诺贝尔奖获得者生理学或医学奖授予澳大利亚科学家巴里,33,magnifying,endoscopy,magnifying,34,図食道粘膜表在血管網,Submucosal drainage vein,Arborescent vessel:,樹枝状血管網,Intra-papillary capillary,loop (IPCL,),図通常近接観察樹枝状血管網,Intra-papillary capillary loop (IPCL),図食道粘膜表在血管網図通常近接,35,顕微鏡像（,HE,染色、 ）,Intra-papillary capillary loop,(IPCL),拡大内視鏡像,(,150),顕微鏡像（HE染色、 ）Intra-papillar,36,染色,IPCL,変化組合分類。,Type ,：正常,Type ,：薄染、,IPCL,軽度,変化見場合炎症相当,Type ,：不染、,IPCL,変化,、,dysplasia with mild atypism,相当病変,Type ,：不染、,IPCL,変化中等度,、（内,3,個内）、,moderate-severe dysplasia,相当,病変,Type :,不染,IPCL,変化顕著,、（内）、,m, 相当病変,放大内镜诊断标准,染色IPCL変化組合分類。放大内镜,37,放大内镜浸润深度的诊断标准,放大内镜浸润深度的诊断标准,38,胃小区,呈多角形，直径约,2,3mm,的凸出部份,数个至数十个胃小凹组成胃小区,胃小凹是一个腺体的开口,胃小沟是胃小区内腺体的共同开口，具有一定间隔和犹如迷路状的形态,整个胃粘膜约有,350,万个胃小凹,gastric area,gastric pit,胃小沟,gastric groove,胃小区gastric area gastric pit 胃小,39,胃小区,胃小凹,凹陷的小白点,白色部分为小突的边缘,即腺口周围的上皮细胞层,红点即是表层毛细血管网在,小凹上皮内的分布,Gastric area and Gastric pit,胃小区, 胃小凹 白色部分为小突的边缘Gastric are,40,Fundic gland: distributed in fundus and body,1500,万,(one thousand and five million),Fundic gland: distributed in f,41,A,AB,B,BC,C,CD,D,Sakaki et al . Gastroenterol Endosc 1980,Gastric pit pattern classification,(ABCD),fundus, body,Antrum,AABBBCCCDDSakaki et al . Gastr,42,正常胃的,Pit pattern,正常由胃体到胃窦观察可见胃小凹由点状经短线状向连续线状过度（,A-B-C,型）,胃底,胃体,胃窦,交界,A,B,C,点状,短线状,树枝、条纹状或小,沟状,正常胃的 Pit pattern 正常由胃体到胃窦观察可见胃,43,点状型,沟状型,网状型,不规则型,破坏型,异常血管型,腺瘤和,IIa,的放大内镜所见,点状型沟状型网状型不规则型破坏型异常血管型腺瘤和IIa的放大,44,凹陷性早期胃癌的放大内镜所见,分化型腺癌,粗大网状及不规则型,低分化,未分化型腺癌,破坏型，异常血管,IIc,早期胃癌的放大内镜所见,:,粗大不规则型,破坏型,无结构型,yamaguti et al.,消化内镜,13: 2001,凹陷性早期胃癌的放大内镜所见分化型腺癌低分化未分化型腺癌I,45,I,II,IIIs,III,L,IV,V,A,V,N,Tubular or round pit that is larger than the normal pit ( typr I ),Tubular or round pit that is smaller than the normal pit ( typr I ),Asteroid pit,Amorphous or non-structural pit pattern,Irregular arrangement and sizes of III,L, IIIs, IV-type pit pattern,Dendritic or gyrus-like pit,Round pit (normal pit),Pit pattern classification of the colon,Kudo S et al. gastrointest endosc 44: 1996,IIIIIIsIIILIVVAVNTubular or ro,46,病理,:,增生性息肉,普通内镜,:,增生性息肉,色素内镜,:,与正常粘膜相同的结构,(,靛胭脂,),放大内镜,: II,型,pit,放大内镜,: II,型,pit,增生性息肉,Pit pattern II,病例,1,升结肠有,10mm,的表面平坦的白色隆起性病变,病理: 增生性息肉普通内镜: 增生性息肉色素内镜: 与正常粘,47,病例,2,回盲部有轻度的粘膜充血,普通内镜,:,粘膜充血,色素内镜,: 12mm,界限清楚的扁平隆起,(,靛胭脂,),色素内镜,:,边缘突起,放大内镜,: II,型,pit,增生性息肉,病理,:,增生性息肉,Pit pattern II,病例 2普通内镜:粘膜充血色素内镜: 12mm界限清楚的扁平,48,普通内镜,:,诊断困难的隆起性病变,色素内镜,:,界限清楚的边缘不规则突起,(,靛胭脂,),色素内镜,:,周围结构相同,病例,3,横结肠有白色平滑的,12mm,隆起性病变,放大内镜,: IIIL,型,pit,肿瘤性息肉,病理,:,中度异性性腺瘤,Pit pattern III,L,普通内镜:诊断困难的隆起性病变色素内镜: 界限清楚的边缘不规,49,Endoscopic ultrasonography,（,.,MH,）,第,1,層：粘膜,层,(m),高回声,第,2,層：粘膜,肌层,(mm),低回声,第,3,層：粘膜下,层,(sm),高回声,第,4,層：固有,肌层,(mp),低回声,第,5,層：外膜,(a),高回声,Endoscopic ultrasonography第1層：,50,Endoscopic ultrasonography,(20MHz),epitheli,u,m (m1),lamina propria (m2),muscularis mucosa (m3),submucosal layer (sm),borderline echo,inner,circular muscularis,(,MP,),borderline echo,outer,longitudinal,muscularis,(,MP,),adventitia,Endoscopic ultrasonographyepit,51,癌,粘膜上皮,(ep),粘膜固有層,(lpm),粘膜筋板,(,mm,),粘膜下層,(,sm,),境界,固有筋層内輪筋,(,mp,),境界,固有筋層外縦筋,(,mp,),外膜,(,a,),Endoscopic ultrasonography,(,20 MH,z),癌Endoscopic ultrasonography(,52,N,分期,N0,无淋巴结转移,N1,区域淋巴结转移,N分期N0 无淋巴结转移,53,Endoscopic Mucosal,Resection,(EMR,),Endoscopic,Submucosal,Dissection (ESD),Endoscopic Mucosal Resection (,54,EMR,ESD,适应症,绝对适应症,相对适应症,深度,m1,、,m2,m3,、,sm1,直径,3,cm,3 - 5cm,周性,2/3,周性,2/3,-,全周性,病灶数,3 - 4,个,5 - 8,个,EMR, ESD适应症 绝对适应症 相对适应症深度m,55,M, 73,岁,，,25-27cm,，,0-IIc, 23,14mm,a:,普通内镜,b:,色素内镜,c:,放大内镜,：,IPCL,延长,，,弯曲,大小不一,，,1,d:,超声内镜,：,m1,EMR: squamous cell carcinoma, pT1a(m,), ly0, v0,M, 73岁，25-27cm，0-IIc, 2314mm,56,M, 68,岁,，,Lt,，,0-IIc,a:,普通内镜,b:,色素内镜,c:,放大内镜,：,IPCL(,延长,弯曲,不均一，,2),d:,超音波内視鏡：,2,EMR: Squamous cell carcinoma, pT1a(pLPM,，,m2,),，,ly0,，,v0,M, 68岁，Lt，0-IIc,57,M, 79,岁,，,35-37cm,，,0-IIc+IIa,怀疑,m2,a:,普通内镜,b:,色素内镜,c:,放大内镜,：,IPCL,延长，弯曲，融合,m,d:,超声内镜,：,m,3,EMR: squamous cell carcinoma, pT1a(m3), ly0, v0, ie(-), pLM(-), pVM(-),M, 79岁，35-37cm，0-IIc+IIa, 怀疑m2,58,M, 79,歳，,27cm,，,0-IIc, 8,8mm,怀疑,m3,a:,普通内镜,b:,色素内镜,c:,放大内镜,：,IPCL,延长,，,弯曲,不均一，異常血管，,sm1,d:,超声内镜,：,sm1,EMR: squamous cell carcinoma, pT1b(sm1), ly1, v0, ie(+), pLM(+), pVM(+),M, 79歳，27cm，0-IIc, 88mm, 怀疑m3,59,M, 68,岁,食道,35cm,，,0,-,IIb,，,a:,普通内镜,b:,色素内镜,c: IPCL(,延长,，,弯曲,，,口径不同,，,),ESD: papillary adenocarcinoma,pT1a( pLPM, M2),ly0,v0,pEM(-),Endoscopic Submucosal Dissection (ESD),M, 68岁, 食道35cm，0-IIb， a,60,治疗成绩,治疗成绩,61,壁深達度,m1,m2,m3,sm1,sm2,3,計,症例数,22,16,9,96,143,脈管浸潤,4.5%,56,78,97,77%,節転移,0%,6,11,47,33%,表在食道癌節転移,壁深達度症例数脈管浸潤節転移表在食道癌節,62,壁深達度,m1,m2,m3,sm,T,urumaru,1994(n=120),0%,16%,50%,Momma,1994(n=79),0%,11%,42%,M,itami,1994(n=105),0%,9%,40%,Kodama,1995(n=1,740),1.4%,12%,39%,早期癌淋巴结转移率,壁深達度TurumaruMommaMitamiKodama早,63,0,1,2,3,4,5,6,7,8,9,10,0,20,40,60,80,100,99.5%,98.6%,96.3%,93%,89.3%,85%,80.1%,75.7%,70%,100%,Gawata,et al,.,胃腸,.,2007,;,8,:,1317-1322,m1m2,食管癌,EMR,后生存曲线,(1989-2005),01234567891002040608010099.5%9,64,，歳，,.,普通内镜,b.,色素内镜,c.,放大内镜,：,粗大网状,.,超声内镜,：（）,a,b,c,d,胃镜,(,普通,，色素,放大,，,超声,),，歳，abc,65,，,70,歳，,SD:,，（），（），（）,Endoscopic Submucosal Dissection (ESD),，70歳，E,66,M, 85,岁,，,胃窦,小弯，,IIc,a:,普通内镜,b:,色素内镜,c:,放大内镜,：,网状,d:,超声内镜,：,m1,ESD: well differentiated adenocarcinoma,pT1(m1), ly0,，,v0, pLM(-), pVM(-),M, 85岁，胃窦小弯，IIc,67,M, 71,歳，胃角前壁，,IIc,a:,普通内镜,b:,色素内镜,c:,放大内镜,：,网状结构,d:,超声内镜,：,M,ESD: well differentiated adenocarcinoma(tub1),，,pT1(M),，,ly0, v0, pLM(-),pVM(-),M, 71歳，胃角前壁，IIc,68,F,，,岁,，,Rb,，,LST,G,，,直径,：,mm,，,ESD,普通内镜,b.,靛胭脂,c.,放大内镜,：,VA,d.,放大内镜,：,IV e.,超声内镜,：,M,Colon EMR,：,Well to moderately differentiated adenocarcinoma,m,Endoscopic Submucosal Dissection (ESD),F，岁，Rb，LSTG， 直径：mm，ESD,69,F,，,79,岁, S 25cm, LST-G, 25mm,a:,普通内镜,:,b:,放大内镜,：,VA,c:,放大内镜,：,VA,d:,超声内镜,：,m,ESD: well to moderately differentiated adenocarcinpma, M, ly0, v0,pLM(-), pVM(-),F，79岁, S 25cm, LST-G, 25mm,70,F,，,66,岁,，,Rb, Isp,2020mm,a:,普通内镜,:VA,b:,放大内镜,：,V A,c:,超声内镜,：,SM1,ESD: adenocarcinoma,（,wel mod,）,sm1,ly0,v(+),F，66岁，Rb, Isp,2020mm,71,血液是传播和折散光的媒介,血红蛋白更具有分光吸收特性,对光的吸收和反射具有非同步,散射性,波长依赖性,Narrow-band,ing,imaging,(NBI),血液是传播和折散光的媒介Narrow-banding ima,72,415 nm,500 nm,Colour adjustment,NBI,image,Whte light,NBI filter,Narrow band illuminations,445 nm,605nm,540nm,415nm,415 nm 500 nm Colour adjust,73,M, 35,岁,交界部,0,-,I,型,10mm,Barrett,腺癌,？,网状, EUS:,SM3,ESD,:,Adenocarcinoma,incompletely excided,M, 35岁, 交界部, 0-I型, 10mm, Barre,74,Auto Fluorescence Imaging,(AFI),胃肠道组织中存在不同浓度的荧光集团,病变组织发生生化改变,粘膜层的厚度和血供发生变化,组织各层内在的荧光改变,正常粘膜呈绿色荧光,不典型增生和癌粘膜无绿色荧光,呈,红色,或,紫色,尤其是不典型增生和癌变的边缘,Auto Fluorescence Imaging胃肠道组织,75,408nm,蓝色激光,Auto Fluorescence Imaging,(AFI),408nm Auto Fluorescence Imagin,76,红外线内镜,红外线波长,700nm,较可见光容易穿透组织,更准确的判断早期癌的浸润深度,红外线内镜红外线波长700nm,77,Natural Orifice Translumenal,Endoscopic Surgery,Natural Orifice Translumenal,78,