診斷學 第15講胃腸道內(nèi)鏡檢查

醫(yī)院消化科胃腸道內(nèi)鏡檢查GastrointestinalEndoscopy胃腸道內(nèi)鏡的分類及發(fā)展史

纖維、電子內(nèi)鏡工作原理與構(gòu)造電子內(nèi)鏡檢查的適應癥和禁忌癥電子內(nèi)鏡檢查常見病變的診斷和治療胃腸道內(nèi)鏡診斷及治療進展主要內(nèi)容內(nèi)鏡內(nèi)鏡為經(jīng)體表插入器械。窺視有關臟器的變化。早期用于診斷。目前已成為介入治療不可缺少的工具。Endoscope消化道內(nèi)鏡分類（一）上消化道內(nèi)鏡檢查（Uppergastrointestinalendoscopy）食管鏡

(Esophagoscope)胃鏡

(Gastroscope)

十二指腸鏡

(Duodenoscope)

消化道內(nèi)鏡分類（二）下消化道內(nèi)鏡檢查（Lowergastrointestinalendoscopy）小腸鏡

(Enteroscope)結(jié)腸鏡

(Colonoscope)硬式內(nèi)鏡（Rigidendoscope）纖維內(nèi)鏡（Fiberopticendoscope）電子內(nèi)鏡（Videoendoscope）膠囊內(nèi)鏡（Capsuleendoscope）雙氣囊電子小腸鏡(Double-balloonEnteroscopy)

超聲內(nèi)鏡（Ultrasonicendoscope）放大內(nèi)鏡（magnifyingendoscope）內(nèi)鏡的發(fā)展史

硬式內(nèi)鏡（1805-1932）早期硬式內(nèi)鏡：1805年德國Bozzine首先提出了內(nèi)鏡的設想，他利用燭光做光源，通過內(nèi)鏡看到了直腸和子宮的內(nèi)腔；1826年法國的Segales研制成功了膀胱鏡與食管鏡；1869年德國Kussmaul制成了第一臺胃鏡。半可曲式胃鏡（Semiflexiblelensgastroscope）1932年光學師Wolf和內(nèi)鏡學者Schindler共同研制成功了一種半可曲式胃鏡。纖維內(nèi)鏡（1957--）1957年美國的Hirschowits制成了第一臺纖維內(nèi)鏡，日本1963年開始生產(chǎn)纖維胃鏡。電子內(nèi)鏡（1983--）1983年美國WelohAllyn公司首先開發(fā)了世界上第一臺電子胃鏡（Videoendoscope）膠囊內(nèi)鏡（2000）2000年以色列開發(fā)出第一臺將圖像連續(xù)發(fā)射至體外的醫(yī)學照像機，這一臺照像機外形酷似藥品的膠囊，故俗稱膠囊內(nèi)鏡（Capsuleendoscope）雙氣囊電子小腸鏡

推進式電子小腸鏡加上兩個小小的氣囊，便使其能夠到達前任所不能到達的地方日本自治醫(yī)大醫(yī)院Yamamoto醫(yī)師最早使用超聲內(nèi)鏡（2000）超聲內(nèi)鏡（EUS）是將微型的超聲探頭安置于內(nèi)鏡的前端，在內(nèi)鏡觀察上消化道的異常改變的同時，可在距病灶最近的位置對病灶進行超聲.放大內(nèi)鏡（2000）通過內(nèi)鏡放大技術可以觀測到胃小凹和腸黏膜的細微結(jié)構(gòu)的各種變化.通過它可以得到約100倍（14英寸以上監(jiān)視器）的高分辨率大畫面纖維內(nèi)鏡構(gòu)造

內(nèi)鏡操作部鏡身光源系統(tǒng)附件活檢與治療器械攝影及視頻信號采集保存操作部鏡身光源纖維內(nèi)鏡工作原理

光源的強光經(jīng)導光束照亮消化管內(nèi)腔，圖像由物鏡、導光束傳至目鏡后觀察。通過附件，可在內(nèi)鏡直視下做活組織檢查及攝影等。

電子內(nèi)鏡電子內(nèi)鏡由操作部、插入部、先端部、接續(xù)部構(gòu)成，接續(xù)部與視頻系統(tǒng)主體相連，通過監(jiān)視器來觀察傳輸回來的圖像。

操作部分配有控制內(nèi)鏡向上下左右彎曲的角度旋鈕、送氣送水按鈕、吸引按鈕以及插入診療附件的鉗子管道觀測系統(tǒng)（彩色監(jiān)視器、中央處理器、光源裝置）該監(jiān)視器具有使用最尖端技術的CCD和極細電子內(nèi)鏡，可以呈現(xiàn)高清晰度的圖像。電子內(nèi)鏡構(gòu)造電子內(nèi)鏡工作原理用電荷耦合器件（CCD）代替纖維鏡之導向束將光信號轉(zhuǎn)變?yōu)殡娦盘栐诒O(jiān)視器上進行觀察其余部分與纖維內(nèi)鏡相似胃鏡檢查的適應癥(一)

Indicationsof

Gastroscopy消化不良胸骨后疼痛、燒心、上腹疼痛、不適飽脹、食欲下降吞咽困難上消化道出血消瘦、貧血疑有上消化道腫瘤鋇餐檢查不能確診病變隨訪病變胃潰瘍、萎縮性胃炎、術后胃、反流性食管炎、Barrett食管等藥物治療前后、手術后需要內(nèi)鏡治療摘取異物、上消化道出血的止血及食管靜脈曲張的硬化劑注射與結(jié)扎、食管狹窄的擴張治療、上消化道息肉摘除胃鏡檢查的適應癥(二)胃鏡檢查的禁忌癥(一)

Contraindicationsof

Gastroscopy嚴重心肺疾患嚴重心律失常、主動脈瘤、心力衰竭、心肌梗塞活動期嚴重呼吸功能不全及哮喘發(fā)作期休克、昏迷神志不清、精神失常食管、胃、十二指腸穿孔急性期特殊病變嚴重咽喉部疾患腐蝕性食管炎和胃炎巨大食管憩室嚴重頸胸段脊柱畸形暫緩檢查疾病急性傳染性肝炎或胃腸道傳染病需特別消毒措施慢性乙、丙型肝炎或抗原攜帶者AIDS胃鏡檢查的禁忌癥(二)蠕動波下食管括約肌(LES)loweresophagealsphincter胃底(fundus)

胃體(body)

食道團胃竇(antrum)十二指腸(duodenum)幽門(pylorus)賁門(cardia)胃解剖圖上消化道胃鏡檢查圖像正常食道正常食管粘膜呈淡紅色或淡黃色，可見毛細血管網(wǎng)。thesquamocolumnarjunctionThesquamocolumnarjunction.Consideredasthetransitionalzonebetweenthesquamousandcolumnarepitheliumofthedistalesophagus.Itisusuallylocated1-2cmabovethecardiasandisidentifiedbyanabruptchangeincolor.Thejunctionshowsconsiderablevariationsandinsomeinstancesishardlyobserved1cmLAGradeAOne(ormore)mucosalbreaknolongerthan5mm,thatdoesnotextendbetweenthetopsoftwomucosalfoldsLAGradeB1cmOne(ormore)mucosalbreakmorethan5mmlong,thatdoesnotextendbetweenthetopsoftwomucosalfoldsLAGradeC1cmOne(ormore)mucosalbreakthatiscontinuousbetweenthetopsoftwo

ormoremucosalfolds,butwhichinvolveslessthan75%ofthecircumferenceLAGradeD1cmOne(ormore)mucosalbreakwhichinvolvesatleast75%oftheoesophagealcircumferenceLundelletalGut45:172-180(1999)LosAngelesclassificationof

refluxoesophagitisDiagnosisMild–ModerateSevereVerySevereRefluxEsophagitisEsophagealerosions.

Areusuallylinear,longitudinallyorientedandnotuncommonlycoveredwithexudates

Barrett'sEsophagus

Barrett'sesophaguswithanirregularsquamocolumnarjunctionextendingupwardsasymmetricallyLugolstaininginBarrett'sesophagus.

ThecolumnarepitheliumofBarrett'sesophagus(glycogendepleted)remainsunstainedwhilethenormalnon-keratinizedsquamousepithelium(abundantinglycogen)isstained

brown食管賁門粘膜撕裂綜合征(Mallory-Weisssyndrome)食管下端賁門大彎側(cè)粘膜縱行撕烈，有血跡。EsophagealVaricesSlightlytortousvenoustrunksrunninglongitudinallythroughtheesophagusEsophagealCancerFungatingandpartiallyulceratedadenocarcinomaoftheloweresophaguscausingobstructioinTheNormalStomachTherugalfoldsofthebodyrunninglongitudinallytowardstheantrumNormalstomach

Arelativelyshortbutnormalstomachwithashapethatpermitstheobservationofboththefornixandpyloruswhileretrovertingtheinstrument'stip.ThefornixandcardiaThefornix(thevaultofthestomach)andthecardia(surroundingtheinstrument'sshaft)arebetterobservedbyretrovertingtheinstrument'stip.Differentbutnormalconfigurationsoftheantrum.AsymmetricalcontractionisobservedonthelowerrightClose-upviewofthepylorus

ChronicGastritis

DiffusemilderythemaofthecorpuschronicathrophicgastritisIncreasedvisibilityofthevascularpatternoftheantrumwithfindingscompatiblewithchronicathrophicgastritisassociatedwithH.pyloriinfection胃粘膜出血(Gastricbleeding)胃粘膜條狀出血。StagesofGastriculcerA1A2H1H2S1S2BenignGastricUlcers

Definition

Mucosaldefectspenetratingthroughtheoftheuppergastrointestinaltractthatoccurasaresultofanimbalancebetweenaggressivefactors(gastricacid,pepsin)andgastroduodenaldefensemechanisms.Benigngastriculcerswithacleanbase.a:Spurtinga:Visiblevesselb:Oozingb:AdherentclotC:Flatpigmentedspot

TypeITypeIIForrestClassificationofbleedingpepticulcersType

Ⅲ

Cleanbase急診胃鏡的概念：urgentendoscopy上消化道出血后24-48小時內(nèi)進行的胃鏡檢查為急診胃鏡檢查。Applicationsforemergency

EndoscopyLocationandidentityofthebleedingsourceWhetherbleedingiscontinuingWhetherbleedingisarterialWhichofmultiphelesionsisbleedingWhetheravisiblevesselispresentinanulcerbaseApplicationsforemergency

EndoscopyuppergastrointestinalbleedingInjectionTherapyuppergastrointestinalbleedinghemoclippingtechniqueuppergastrointestinalbleedingheaterprobeTherapyuppergastrointestinalbleedingInjectionTherapy

Thiscasecorrespondstoapatientpresentingmassiveuppergastrointestinalbleeding.AtendoscopyaDieulafoy-likelesionwithoozingwasfoundatthecardia.Combinedtherapywithinjectionandhemoclipping(nextpage)wassuccessfuluppergastrointestinalbleedinghemoclippingtechniqueSequentialimagesdemonstratingthehemoclippingtechniquetocollapsethebleedingvessel.HeaterProbe

Oozebleedingduringtheinitialtreatmentwiththeheaterprobeofthisangiodysplasia動畫片Dieulafoy，sdisease：杜氏?。?/p>

又稱胃黏膜下橫徑動脈破裂出血：占消化道出血的0.3%-6.7%，多見于中老年男性，可發(fā)生于消化道的任何部位。Fundicglandpolypsofthestomacharesmall,singleormultiple,non-neoplasticprotrusionsmainlylocalizedinthecorpusandfornixofthestomachFundicGlandPolypsSubmucosalTumorsoftheStomach

SmallbenignsubmucosaltumorsofthestomachwithcompletelyintactmucosaBorrman'sClassificationofAdvancedGastricCancerBorrman'sClassificationofAdvancedGastricCancerBorrman'sClassificationofAdvancedGastricCancerBorrman'sClassificationofAdvancedGastricCancerBorrmantype1Adenocarcinoma

Partiallyulceratedpolypoidadenocarcinomaofthecardiacregion.Borrmantype2Adenocarcinoma

UlceratedadenocarcinomaoftheantrumwithdeformityofthelumenBorrmantype3Adenocarcinoma

Infiltratingandpartiallyulceratedadenocarcinoma.Borrmantype4Adenocarcinoma

Diffuselyinfiltratingadenocarcinomawiththickeningofthefoldsandlossofwallelasticity.TheNormalDuodenum

TheduodenalbulbseenafterjustpassingtheinstrumenttipthroughthepylorusDifferentviewsoftheduodenalpapillaasobservedwithaforwardviewinginstrument..duodenitisFourexamplesofpepticduodenitiswithwhiteexudatesanderythemaoftheduodenalmucosaDuodenalulcer

SmallulcerwithfibrinoidnecrosisandsurroundingerythemaontheanteriorwalloftheduodenalbulbDuodenalAdenocarcinoma

Infiltrating,stenoticandpartiallyulcerated,easybleedingadenocarcinomaofthedescendingduodenum.TherapeuticapplicationsofEndosocopyRemovalofforeignbodiesDilationofbenignormalignantesophagealstricturesSclerotherapyofbleedingesophagealvarices(Varicealbanding)ElectrocoagulationoffocalbleedinglesionsPolypectomyDilationofachalasiaPlacementofendoprotesisLeft:Guidewirepassingthroughthemalignantstricture.Right:Expandedmetalstentwiththetipofendoscopereachingitsproximalpart.EndoscopicvaricealligationAfteridentifyingthetargetvarix,endoscopicsuctionisactivatedandthevarixsuctionedintotheligatingcylindertofinallyreleasetheelasticring.Superficialulcerationsappearingafewdaysafterligationtherapy.Elasticringsstillremaininginnecrosedareas.InjectionSclerotherapyofEsophagealVaricesAtpresent,injectionsclerotherapyislessfrequentlyused.Itisagoodalternativeincasesofactiveandprofusebleedingwhereendoscopicviewisdiminishedor,asinthiscase,totheinabilitytopasstheupperesophagealsphincterwiththemountedligatingcylinder.HotBiopsyPolypectomy

Asmallpolypisvisualizedatthecardia.Aftergraspingandpullingthepolypwiththebiopsyforcepselectrocauteryisappliedcoagulatingthebasethatbecomeswhite(zoombyplacingthepointerontherightlowerimage).SnarePolypectomy

Sequentialimagesofapolypectomyaftersubmucosalinjectionof1:10000adrenalineinhypertonicsaline.Theinstrumentisrotatedtogetabetterworkingpositionandthepolypsnared.Finallyelectrocoagulationisappliedandtransectionachieved.DuodenalAdenoma

Sessileadenomaoftheduodenumexcisedwithsnarepreviousinjectionofadrenalineandhypertonicsaline下腹痛、腹瀉、便血貧血、腹部腫塊、消瘦鋇灌腸檢查有異常者隨訪觀察結(jié)腸癌前病變結(jié)腸癌術后需腸鏡下治療者對比觀察藥物或手術治療前后IndicationsofColonoscopy結(jié)腸鏡鏡檢查的適應癥重點肛門直腸嚴重狹窄畸形急性重度結(jié)腸炎重癥痢疾、潰瘍性結(jié)腸炎及憩室炎急性彌漫性腹膜炎腹腔臟器穿孔妊娠嚴重心肺功能衰竭精神失常及昏迷者Contraindicationsof

Colonoscopy結(jié)腸鏡鏡檢查的禁忌癥重點大腸的內(nèi)鏡圖像Approachingtheileocecalvalvefromthedistance!Thevalveisinitiallyseenasayellowishareawithanindentationbesidethececum.TheNormalRectum

ThetranslucentrectalmucosawithitsclearvascularpatternandprominentHoustonvalves.Submucosalvesselsseenthroughthetranslucentcolorectalmucosa.TheAppendix

orificeOneachimageidentifytheappendixorificewiththemousepointer.LymphocyticColitisUlcerativeColitisRectalstumpwithspontaneousbleedingandmucosalexudatesUlcerativeColitis動畫片Crohn'sdisease

Linearulcerationsintheterminalileum.IschemicColitisApalehypoperfundedareasurroundedbymultiplepetechiaeIschemicColitis

LongitudinalinvolvementofthedescendingcolonwithaswollenmucosaaccompaniedbyhemorrhageandexudatesHyperplasticPolypsoftheColonandRectum

Smallhyperplasticpolypoftherectum.Exophyticadenomasofthecolonandrectum

SmallsessileadenomasofthecolonandrectumNon-exophyticColorectalAdenomas

Non-exophyticadenomawithdepression,initiallyseenasareddishareaAdvantagesofChromoscopySmallepithelialneoplasiascanbetterbeobservedanddelimitedbyusingchromoscopymethods.Inthepresentcase,aslightredareawithindistinctbordersisseenontheleftimage(findtheaffectedareawiththemousepointer).Afterchromoscopywithindigocarmine,thelesioniswellcircumscribed.ColonLymphomaPrimarylymphomaofthesigmoidcolonpresentingwithmarkednodularityandinfiltratingdiffuselythecolonicwallbutleavingintactthemucosalsurface.EarlyColorectalCancer

Depressedtype

AdvancedColorectalCancer

ExophyticcolorectalcancerwithcentralexcavationAdvancedColorectalCancer

Exophyticnon-ulceratedcolorectalcancer.HotBiopsyPolypectomy

Asmallpolypisgraspedandpulledwiththebiopsyforcepsandthereafterelectrocauteryisapplied.Thebasethenbecomeswhite.

SnarePolypectomiApedunculatedadenomawithalongstalkthatfacilitatesitsremovalwithasnare消化內(nèi)鏡診斷及治療進展

內(nèi)鏡下早期胃癌的診斷和治療微小胃癌（microgastriccancer）為病灶最大徑≤5mm的早期胃癌小胃癌（smallgastriccancer）為病灶最大徑>5-10mm的早期胃癌早期胃癌的特殊類型早期胃癌的相關概念胃癌前狀態(tài)（precancerouscondition）癌前疾病（precancerousdiseases）癌前病變（precancerouslesions）癌前疾?。╬recancerousdiseases）與胃癌相關的胃良性疾病有發(fā)生胃癌的危險性，為臨床概念如慢性萎縮性胃炎、胃潰瘍、胃息肉、手術后胃、肥厚性胃炎、惡性貧血等癌前病變（precancerouslesions）已證實與胃癌發(fā)生密切相關的病理變化即異型增生[上皮內(nèi)瘤變（intraepithelialneoplasia）]，為病理學概念。

早期胃癌的相關概念癌前病變：異型增生【低級別上皮內(nèi)瘤變=輕度和中度異型增生，高級別上皮內(nèi)瘤變=重度異型增生和原位癌】

早期胃癌的相關概念低級別上皮內(nèi)瘤變圖d胃的原位癌應是指癌細胞僅限胃腺管內(nèi)尚未突破腺管基底膜的癌。

ConceptofearlygastriccancerEarlygastriccancerisdefincedasbeingconfinedtothemucosaorthesubmucosa,regardlessofthepresenceortheabsenceofregionallymph-nodemetastasis.早期胃癌(earlygastriccancer，EGC)是指局限于胃黏膜層或黏膜下層癌，不管有無淋巴結(jié)的轉(zhuǎn)移。MacroscopictypesofearlygastriccancerType0:Superficial,flattumorswithorwithoutminimalelevationordepressionType0－ⅠType0－ⅡaType0－ⅡbType0－ⅡcType0－ⅢSubtypesoftype0ProtrudedtypeSuperficialelevatedtypeFlattypeSuperficialdepressedtypeExcavatedtypeGastriccancer(1998)1:10-24胃黏膜局部顏色的輕度變化：變紅或變白；黏膜下血管網(wǎng)的消失；黏膜顆粒樣變厚或凹陷等。早期胃癌的內(nèi)鏡下表現(xiàn)EarlyGastricCancerIIctypeearlygastriccancerseenasanerodedareaonthemajorcurvature色素胃鏡(chromoendoscopy)指把一定濃度的色素或染料噴灑或涂布于胃黏膜使普通胃鏡下觀察到的病灶變得更加清晰明確的一種胃鏡診斷方法。目前常用0．2％靛胭脂indigocarmine，IC)噴灑涂布整個胃黏膜或黏膜的可疑病變處沉積在胃小凹的靛胭脂呈現(xiàn)淺藍色與胃黏膜的橘紅色形成了鮮明的對比。

Gastricadenomaonthemajorcurvatureseenasanon-welldefinedsessileelevation.Afterindingocarminesprayingthelesionbecomesclearer色素內(nèi)鏡下早期胃癌可以表現(xiàn)為：表面呈現(xiàn)顆粒樣或結(jié)節(jié)樣凹凸異常。顏色發(fā)紅或褪色，黏膜下的血管紊亂或消失。病變區(qū)易出血，黏膜僵硬等；靛胭脂的染色可以使活檢有更好的針對性。放大胃鏡(magnifyingendoscopy，ME)具有高像素和高分辨率特點的電子內(nèi)鏡可達到與解剖顯微鏡相同的觀察水平有利于觀察微細結(jié)構(gòu)變化Tajiri等發(fā)現(xiàn)，普通內(nèi)鏡對EGC總診斷準確率為66．7％放大內(nèi)鏡為91．7％。超聲胃鏡(endoscopiculrasonography。EUS)可以清晰地觀察到胃黏膜的黏膜層、黏膜肌層、黏膜下層、固有肌層、漿膜層5層結(jié)構(gòu)可以準確地測定出胃壁各層的厚度因此可以用來判斷早期胃癌的浸潤深度和有無周圍淋巴結(jié)轉(zhuǎn)移共聚焦胃鏡

(confocallaserendomicroscopy

)在內(nèi)鏡末端加上一個極小的激光共聚焦顯微鏡它最高可使內(nèi)鏡下的圖像放大1000倍，利用它可以清晰地顯示胃粘膜小凹、細胞以及亞細胞水平的顯微結(jié)構(gòu)。它所顯示的是胃黏膜的同一水平橫斷面的顯微圖像，而不能同時顯示胃黏膜的5層結(jié)構(gòu)。窄帶成像(narrowbandimagingNBI)普通內(nèi)鏡光源發(fā)出寬波光，能展現(xiàn)黏膜的自然原色但是對黏膜淺表血管或黏膜組織狀態(tài)（即pitpatterns）的細微變化的強調(diào)效果并不明顯。NBI利用光的傳導和吸收特性(波長短者深入到胃黏膜的厚度淺，波長長者深入到胃黏膜的厚度深)將傳統(tǒng)寬光譜的紅、綠、藍三色濾色鏡換成窄光譜短波長的光源使胃鏡檢查對黏膜表層的血管影像顯示更加清楚。Treatmentstrategyofearlygastriccancer

EMR

andESDEndoscopicmucosalresection(EMR)Endoscopicsubmucosaldissection(ESD)EndoscopicresectionStandardEMRmethodsEMRStripbiopsyCap-fittedpanendoscopeEMRwithligations(EMR-C)(EMR-L)ERHSEBy1984anEMRtechniquecalledthe“stripbiopsy”wasfirstdescribed

adouble-channelendoscopeisusedAftersubmucosalinjectionofsalineunderthelesionthelesionisliftedusingagrasper,whileasnare,insertedthroughthesecondworkingchannel,isusedtoremovethelesion.StripbiopsyERHSEIn1988anothertechnique,EMRwiththelocalinjectionofhypertonicsaline/dilutedepinephrinesolutionwasdescribed.aftertheinjectionofhypertonicsalineanddilutedepinephrine.Theperipgeryofthelesioniscutusinganeedleknifethelesionisthenremovedusingasnare.高滲鹽溶液注射后粘膜切除術Cap-fittedpanendoscope安裝透明帽的廣視野內(nèi)鏡in1992AmethodofEMRwithacap-fittedpanendoscope(EMR-C)wasdeveloped.Thetechniqueutilizesaclearplasticcapisconnectedtothetipofastandardendoscope.Afterthesubmucosalinjectionofthelesionaspecializedcrescent-shapedsnareisdeployedinthegrooveatthetipofthecapThelesionisthensuckedintothecapresectioncanbesafelyperformedthroughthesubmucosallayerunderthelesion.EMRwithligations(EMR-L)usesastandardendoscopicvaricealligationdevicetocapturethelesionmakeitintoapolypoidlesionbydeployingthebandunderneathit.ThelesionaboveorbelowthebandisthenexcisedEMRtumorslessthan2cminsizeitisdifficulttoresectsuchlargetumorsenblochigherrecurrencerateESDEMRtoESDGanToKagakuRyoho.2007Aug;34(8):1163-7

EndoscopistsdesiredtodevelopanewtechniqueforreliableendoscopicenblocresectionforvariouslesionsEndoknivesforESDSubmucosalinjectionresectinglargerlesionStandardESDmethodsSeveralspotsweremarkedwithaneedleknifeorargonplasmacoagulation5-10mmoutsidemarginofthelesion(1)Afterinjectionof10%glycerinsolutionwith0.0025%epinephrineintothesubmucosaaninitalincisionwasmadewithaneedleknifeoutsidethelineofspotsESD(

2)TheITknifeortheHookknifewastheninsertedintotheinitialincisionelectrosurgicalcurrentwasappliedwiththeuseofanelectrosurgicalgeneratortocompletethecircumferentialmucosalincisionaroundthelesion.ESD(3)InjectionwasrepeatedwithneedlefurtherresectionwascarriedouttoensuretotalremovalofthelesionESD(4)specimenManagementafterESD切除的腫瘤組織要木塊固定Indigocarmine染色測量大小內(nèi)鏡下照相小腸疾病的診斷現(xiàn)狀

SmallintestineConventionallynotreachablebyOGDandcolonoscopyDifficulttodiagnosesmallbowelpathologiesNoMan'sLand!

CommonClinicalProblemsGIbleedingofobscure(unknown)originChronicrecurrentabdominalpainAssessmentofIBD小腸出血的發(fā)病率小腸出血占總GI出血的3-5%小腸出血一般指Treitz韌帶到回盲瓣之間的小腸病變引起的腸道出血50歲以下患者小腸出血的病因以腫瘤最多見，60歲以上以血管畸形更為多見Ghosh，Watts，Kinnear.Managementofgastrointestinalhaemorrhage［J］.PostgraduateMedicalJournal，2002，78（915）：4-14.Concha，Ronald，Amaro，etal.ObscureGastrointestinalBleeding：DiagnosticandTherapeuticApproach［J］.JournalofClinicalGastroenterology，2007，41（3）：242-251.小腸出血的病因?qū)W病名 國內(nèi)

國外血管病變 8-14%

50-70%小腸腫瘤 11-60%

15-20%

良惡性 良>惡

惡>良 部位 空>回

回>空炎癥病變 5-7%

10-15%憩室病 2-3%

5-11%其他 10-20%

10-18%

--張德中《胃腸病學》2002，7（2）：96

小腸出血的檢查手段

一般檢查手段

生化、腫瘤、免疫，CT,MR,GI等

特殊檢查手段

--小腸鋇灌 --99mTc掃描

--電子小腸鏡 --DSA血管造影

--膠囊內(nèi)鏡--

CTenteroclysis

--雙氣囊小腸鏡--FleischerDE,GastrointestEndo,2003,56:452ConventionalInvestigationsPushenteroscopyBamealfollow-throughSmallbowelenemaCTscanCTenteroclysisMesentericangiogramRBCscan（1）雙氣囊電子小腸鏡

(Double-balloonEnteroscopy)(2)雙氣囊電子小腸鏡

(Double-balloonEnteroscopy)工作原理：利用兩個氣囊的相對運動將腸管收縮到外套管上，從而使內(nèi)鏡進得更遠

內(nèi)鏡長度：2m外徑：9mm

檢查時間：較長病人耐受性：在鎮(zhèn)靜或麻醉下進行

檢查路徑:

經(jīng)口、經(jīng)肛及經(jīng)口-經(jīng)肛三種診斷:

病變組織活檢行病理檢查治療:息肉切除，黏膜切除

病變部位:反復觀察經(jīng)口途徑經(jīng)肛門途徑正常小腸黏膜空腸回腸淋巴濾泡正常小腸絨毛空腸絨毛空-回腸多發(fā)性血管

擴張癥伴出血空-回腸交界血管畸形伴出血（手術證實）出血壞死性小腸炎空腸腫瘤伴出血

（胃Ca術后10年，GI出血8年）小腸檢查真正革命性的飛躍是無痛的人性化的膠囊內(nèi)鏡

（CAPSULEENDOSCOPY）

固定電話——手機（1）M2A?CapsuleComponents1.Opticaldome2.Lensholder3.Lens4.IlluminatingLEDs5.CMOSimage6.Battery7.ASIC(ApplicationSpecificIntegratedCircuit)transmitterAntenna

Dimensions:

Height:11mm Width:27mm Weight:3.7gr（2）TheGiven?DiagnosticSystemAmbulatoryDataRecorder?

onabeltRAPID?applicationforimageprocessingandviewingM2A?Capsule(3)HistoryofCapsuleEndoscopyPaulSwain:EndoscopistGavrielIddan:S