内科学版胃癌课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,第五章胃癌,（,gastric cancer,）,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,讲授目的和要求,1.,掌握本病的诊断要点,2.,熟悉本病的临床表现,3.,了解本病的病因、发病机制,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,讲授主要内容,病因和发病机制,病理,临床表现,胃镜检查,实验室,检查,X,线钡餐,诊断,并发症,治疗,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,概述,胃癌系来源于,胃黏膜上皮,的恶性肿瘤，主要是胃腺癌,2008,年新诊断胃癌近,100,万例，病死人数,74,万，占恶性肿,瘤诊断的第,4,位和恶性肿瘤病死率的第,2,位,2/3,分布于发展中国家，地理分布上以,日本,和,中国,等东亚,国家为高发,我国,北方,发病率高于,南方,，,农村,高于,城市,，男性发病率和,死亡率均高于女性，,55-70,岁为高发年龄段,全国平均死亡率约,16/10,万（男性,21/10,万，女性,10/10,万）,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,胃癌的发生是一个多因素、多步骤进行性发展的过程,不良环境,、,饮食,及,Hp,多种因素作用下，,COX-2,及,生长因子,等介导发生连续性慢性炎症，由,慢性炎症,-,萎缩性胃炎,-,萎,缩性胃炎伴肠化,-,异型增生,-,而逐渐向,胃癌,演变,相关癌基因,:ras,、,bcl-2,、,c-myc,相关抑癌基因,:p53,、,APC,、,DCC,、,MCC,相关生长因子,:EGF,、,TGF-,?,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,-,环境和饮食因素,环境因素,美国的日本移民，胃癌发病率逐代下降,火山岩地带、高泥碳土壤、水土含硝酸盐过多、微量元素,比例失调、化学污染可参与胃癌的发生,饮食因素,多吃新鲜水果和蔬菜可降低胃癌的发生,经常食用霉变食品、咸菜、腌制烟熏食品以及过多的食盐，,增加胃癌的危险性,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,-,环境和饮食因素,食物中,硝酸盐,可以被细菌还原成,亚硝酸盐,，与胺,结合生成,亚硝胺,胃内,细菌,增加可以促进,亚硝酸盐类,致癌物的产生,慢性胃炎,、,胃部分切除,、,老年人,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,-,感染因素,Hp,Hp,与胃癌有共同的流行病学特点,胃癌高发区,Hp,感染率,高,;Hp,抗体阳性人群发生胃癌的危险性高于阴性人群,动物实验示,:Hp,可诱发胃癌,1994,年国际癌肿研究机构将,Hp,定为,类,致癌原,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,-,感染因素,Hp,致胃癌的可能机制,:,1,、,Hp,导致的慢性炎症内源性致突变原,胃黏膜萎缩、肠化、不典型增生癌变,2,、,Hp,还原亚硝酸盐，,N,亚硝基化合物是公认的致癌物,3,、,Hp,代谢产物促进上皮细胞变异,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,-,感染因素,其他感染因素,EB,病毒,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,-,遗传因素,胃癌有明显的,家族聚集倾向,，家族发病率高于人群,2-3,倍,据历史记载，拿破仑一家三代人中大多死于胃癌：,祖父,死于胃癌；父亲死于胃癌；,三个妹妹,也均患胃癌；他,本,人,也于,1821,年死于胃癌,少数胃癌属遗传性胃癌易感综合征，,浸润性胃癌,有更高的,家族发病倾向,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,-,癌前状态,癌前疾病,-,指与胃癌相关的胃良性疾病，有发生胃癌的危险,癌前病变,指易转变成癌组织的病理组织学变化，主要指,异型增生,肠型化生：分小肠型和大肠型,异型增生：,胃黏膜腺管结构及上皮细胞失去正常的状态出,现异型性改变，组织学上介于良恶性之间,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和发病机制,-,癌前状态,肠上皮化生、萎缩性胃炎及异型增生,胃息肉,炎性息肉：多,2cm,的广基息肉,胃溃疡,发生率约,0.5%,2%,，多因溃疡边缘的炎症、糜烂、再,生及异型增生所致,残胃炎,毕式胃大部切除术后,10,15,年发生，残胃癌发生率,约,0.6%,2.5%,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病理,好发部位,胃窦,(58%),、贲门,(20%),、胃体,(15%),、全胃或大部,分胃,(7%),早期胃癌,病灶局限且深度不超过黏膜下层的胃癌，而不论有无淋,巴结转移,进展期胃癌,胃癌深度超过黏膜下层，侵及肌层者称中期胃癌；侵及,浆膜或浆膜外者称晚期胃癌,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病理,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病理,-,组织病理学,按腺体的形成及粘液分泌能力又可分为,乳头状腺癌、管状腺癌、粘液腺癌、印戒细胞癌、混合,性腺癌、腺鳞癌、髓样癌、肝样腺癌、鳞状细胞癌和未,分化癌,按分化程度,分化良好、分化中等、分化差,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病理,-,侵袭与转移,直接蔓延,直接侵入邻近器官，,胃底贲门癌,常侵犯食管、肝及大网,膜，,胃体癌,则侵犯大网膜、肝及胰腺,淋巴转移,先局部淋巴结，再到远处淋巴结，最常见，,Virchow,淋巴,结,血行播散,以累及肝脏多见，其次肺、腹膜、肾上腺、肾、脑、骨髓,腹腔内种植,癌细胞脱落入腹腔种植于肠壁和盆腔，如种植于卵巢称,Krukenberg,瘤,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,临床表现,-,症状,早期胃癌,多无症状，部分患者可有消化不良症状,进展期胃癌,上腹痛（餐后加重）、纳差、厌食、乏力、体重减轻,并发症或转移症状,累及食管下段,-,咽下困难、,幽门梗阻,-,恶心、呕吐,上消化道出血,-,呕血或黑粪,胃癌肝转移,-,右上腹痛、黄疸或发热,胃癌肺转移,-,咳嗽、呃逆、咯血,胃癌胸膜转移,胸腔积液、呼吸困难,胃癌胰腺转移,背部反射性疼痛,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,临床表现,-,体征,早期胃癌,无明显体征,晚期胃癌,上腹部包块，上腹压痛,胃癌肝转移,肝大、黄疸、腹水,胃癌腹膜转移,腹水、移动性浊音,侵犯门静脉或脾静脉,脾脏增大,远处淋巴结转移,Virchow,淋巴结,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃镜检查,胃镜结合黏膜活检是诊断胃癌最可靠的手段。确诊率达,95,99%,以上,早期胃癌,好发部位：,胃窦及胃体,胃镜下表现：,息肉样隆起或凹陷、平坦但黏膜粗糙、触,之易出血，斑片状充血及糜烂,染色胃镜,、,放大胃镜,、,窄带光成像,和,激光共聚焦,胃镜,可以提高诊断率,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃镜检查,早期胃癌内镜分类法：,型（息肉样型）：广基无蒂，常,2cm,型（浅表型）：本型最常见，又分三个亚型,a型（浅表隆起型）：病变稍高出黏膜，,0.5cm,b,型（浅表平坦型）：病变表面粗糙呈颗粒状,c,型（浅表凹陷型）：凹陷,0.5cm,，底面粗糙,型（溃疡型）：黏膜糜烂比,c,型深，但不超过黏膜下,层,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃镜检查,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃镜检查,早期胃癌（,型）：胃角上息肉样隆起，表面充血、糜烂、,伴有少许出血，活检示低分化腺癌，手术证实为黏膜内癌,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃镜检查,早期胃癌（a型）：胃窦后壁丘样隆起，,类圆形、表面少许糜烂，活检示印戒细胞癌,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃镜检查,早期胃癌（,型）：胃窦前壁溃疡，形不规则、边不整,基底覆以黄白苔，活检示黏膜内黏液细胞癌,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃镜检查,进展期胃癌,胃镜下表现：,肿瘤表面凹凸不平，糜烂，