超声内镜在消化道疾病诊断中的应用
摘要
目的
探讨超声内镜鉴别诊断消化道病变的价值,重点探讨内镜超声技术在食道隆起性病灶、食道结核、胃间叶源性肿瘤鉴别、胃异位胰腺、胆胰结合部病变等疾病中的诊断价值。
方法
回顾性分析我科内镜室2005年1月至2009年12月2093例行超声内镜检查的患者,总结分析食道、胃粘膜下隆起性病变的超声内镜及内镜特点；比较超声内镜与腹部B超、CT、MRCP在胆胰结合部病变中的诊断能力。
结果
1.研究期间共发现1353例隆起性病变,有明确病理结果的病人例数为327例；虽然无病理结果,但依据内镜及超声内镜、定期随访能明确诊断的病人如消化道管壁的外压性隆起及静脉曲张,其例数为150例。
2.食道隆起性病变共387例；有明确病理诊断的共149例病人,152个病变。与病理结果比较,食道上段、中段、下段病变超声内镜诊断总的准确率及对间叶源性肿瘤、结核、外压病外压性病变诊断的准确率均高于内镜的诊断准确率,尤其是外压性病变,超声内镜食道三段的准确率为100%(36/36)。食道超声内镜下表现为低回声病变236例,以粘膜肌层病变为主。发现9例食道结核,在胃镜下表现为两种形态：(1)小的孤立的隆起性病变,其表面有质子泵抑制剂不能治愈的孔洞或溃疡,超声内镜下呈现为等-低回声、边界清晰、边缘光滑、局部管壁层次清晰完整。(2)表面光滑的较大病变,超声内镜表现为低回声团块影,其内混杂有高回声点状、条状影。
3.胃内病理诊断明确的病变244例,以息肉、间叶源性肿瘤、外压性病变为主。胃平滑肌瘤与间质瘤共55例,胃底为病变最多见部位,占52.7%；其次为胃体,占29.1%。平滑肌瘤和间质瘤的生长形态如表面是否有溃疡、腔内还是腔外生长、是否分叶、边缘是否光滑、内部是否有囊性变及钙化两者比较无差异；而内部回声特点两者有显著差异,平滑肌瘤超声内镜下表现为内部回声均匀,与周围固有肌层的回声相等,常无高回声点。根据间质瘤的病理标准,将间质瘤进一步分类,极低危险度和低危险度间质瘤归类为相对良性间质瘤,中度及高度危险度间质瘤归类为恶性间质瘤,比较两者的超声内镜特征,发现良恶性间质瘤的大小比较,差异有显著性,两者的生长方式、内部回声、边缘等比较差异无显著性；而内部是否有囊性变、钙化差异有显著性,恶性间质瘤内部常有囊性变及钙化。在长径为309cm时,肿瘤为恶性可能性大,其敏感性为0.889,特异性为0.763。
4.胃内共发现18例异位胰腺。胃异位胰腺与GIMT比较,年龄、胃内生长部位、表面粘膜情况、起源层次、病变边缘、内部回声高低及内部有无灶性无回声区方面差异有显著性。异位胰腺相对年轻,病变较小,好发于胃窦,表面可有凹陷性开口,但不占多数；多起源于第三层胃壁,病变边缘多不光滑；与周围粘膜下层及固有肌层回声比较,内部回声多介于两者之间,且有2/3病变内部有灶性无回声区。
5.胆胰结合部病变48例。EUS与腹部B超、CT、MRCP比较,在胆总管下段结石的诊断方面较其他三种方法敏感性、特异性高；在胆胰结合部肿瘤的诊断方面,EUS敏感性、特异性较CT高,与MRCP比较无差异。
结论
1.食道器质性病变以粘膜肌层为主,主要为平滑肌瘤；对粘膜下层的低回声及混合回声病变,需警惕食道结核的存在。
2.胃内的粘膜下隆起性病变以外压性病变为最常见,正常脏器是外压的主要原因。器质性粘膜下病变,胃内主要是间叶源性肿瘤,其次是异位胰腺。超声内镜可以较好地鉴别固有肌层平滑肌瘤和间质瘤。恶性间质瘤相对较大,内部更易出现液化坏死所致的囊性变和钙化。
3.超声内镜是诊断胃内异位胰腺的有效方法,但敏感性不高；超声内镜能为安全有效的内镜下治疗异位胰腺病变提供指导。
4.超声内镜对胆胰结合部病变的诊断有较大的优势。
Objective
To evaluate the effect of endoscopic ultrasonography in diagnosis of gastroenterological leisions and pancreaticobiliary junction lesions.
Methods
Retrospective analyzed the results of2093gastroenterological leisions performed endoscopic ultrasonography from2005January to2009November in a single center.
Results
1. A total1353leisions were included,327leisions were diagnosed pathologically.
2. There were387leisions located at the esophagus, of which149cases,152leisions were diagnoses with pathologically. These diagnosed leisions were mainly leiomyoma from the mucosal of the esophageal wall.
Nine esophageal tuberculosis patients were found that mimic a submucosal tumor under upper endoscopy. Endoscopic ultrasonography showed five patients were with heterogeneous hyperechoic or isoechoic masses and the local wall layers were intact. Two patients were with hypoechoic masses with hyperechoic bands in the parenchyma and the local wall layers were interrupted. Two ulcerative lesions showed hyperechoic interrupted wall layers. A similar echogenic mediastinal lymph node to the near lesion was observed in three patients.
3. In the599gastric patients, EUS found244definitely diagonosised cases;34.43%(84/244) cases of extraluminal compression,47gastrointestinal stromal tumors,18cases of ectopic pancreas,8cases of leiomyoma. The EUS findings confirmed that leiomyomas were smaller than GISTs, and the echo of leiomyoma is similar to the surrounding muclar propria. GISTs had higher echo than the surrounding muclar propria. They were often heterogeneity. When the cut off point was3.9cm, GISTs were tended to be highly malignant.
4. Compared with mesenchymal tumors, ectopic pancreases showed a significant difference in the lesion location, growth pattern, layer of origin, presence of layer disruption, margin, and internal echo (P<0.05). There was no statistical difference in the lesion size and presence of focal anechoic portion.
5. The sensitivity and specialty of EUS are superior to that of ultrasound, CT and MRCP in pancreaticobiliary junction lesions.
Conclusion
EUS is essential in diagnosis and management for gastroenterological leisions. A biliopancreatic EUS has a significant impact on the patient diagnosis.
探讨超声内镜鉴别诊断消化道病变的价值,重点探讨内镜超声技术在食道隆起性病灶、食道结核、胃间叶源性肿瘤鉴别、胃异位胰腺、胆胰结合部病变等疾病中的诊断价值。
方法
回顾性分析我科内镜室2005年1月至2009年12月2093例行超声内镜检查的患者,总结分析食道、胃粘膜下隆起性病变的超声内镜及内镜特点；比较超声内镜与腹部B超、CT、MRCP在胆胰结合部病变中的诊断能力。
结果
1.研究期间共发现1353例隆起性病变,有明确病理结果的病人例数为327例；虽然无病理结果,但依据内镜及超声内镜、定期随访能明确诊断的病人如消化道管壁的外压性隆起及静脉曲张,其例数为150例。
2.食道隆起性病变共387例；有明确病理诊断的共149例病人,152个病变。与病理结果比较,食道上段、中段、下段病变超声内镜诊断总的准确率及对间叶源性肿瘤、结核、外压病外压性病变诊断的准确率均高于内镜的诊断准确率,尤其是外压性病变,超声内镜食道三段的准确率为100%(36/36)。食道超声内镜下表现为低回声病变236例,以粘膜肌层病变为主。发现9例食道结核,在胃镜下表现为两种形态：(1)小的孤立的隆起性病变,其表面有质子泵抑制剂不能治愈的孔洞或溃疡,超声内镜下呈现为等-低回声、边界清晰、边缘光滑、局部管壁层次清晰完整。(2)表面光滑的较大病变,超声内镜表现为低回声团块影,其内混杂有高回声点状、条状影。
3.胃内病理诊断明确的病变244例,以息肉、间叶源性肿瘤、外压性病变为主。胃平滑肌瘤与间质瘤共55例,胃底为病变最多见部位,占52.7%；其次为胃体,占29.1%。平滑肌瘤和间质瘤的生长形态如表面是否有溃疡、腔内还是腔外生长、是否分叶、边缘是否光滑、内部是否有囊性变及钙化两者比较无差异；而内部回声特点两者有显著差异,平滑肌瘤超声内镜下表现为内部回声均匀,与周围固有肌层的回声相等,常无高回声点。根据间质瘤的病理标准,将间质瘤进一步分类,极低危险度和低危险度间质瘤归类为相对良性间质瘤,中度及高度危险度间质瘤归类为恶性间质瘤,比较两者的超声内镜特征,发现良恶性间质瘤的大小比较,差异有显著性,两者的生长方式、内部回声、边缘等比较差异无显著性；而内部是否有囊性变、钙化差异有显著性,恶性间质瘤内部常有囊性变及钙化。在长径为309cm时,肿瘤为恶性可能性大,其敏感性为0.889,特异性为0.763。
4.胃内共发现18例异位胰腺。胃异位胰腺与GIMT比较,年龄、胃内生长部位、表面粘膜情况、起源层次、病变边缘、内部回声高低及内部有无灶性无回声区方面差异有显著性。异位胰腺相对年轻,病变较小,好发于胃窦,表面可有凹陷性开口,但不占多数；多起源于第三层胃壁,病变边缘多不光滑；与周围粘膜下层及固有肌层回声比较,内部回声多介于两者之间,且有2/3病变内部有灶性无回声区。
5.胆胰结合部病变48例。EUS与腹部B超、CT、MRCP比较,在胆总管下段结石的诊断方面较其他三种方法敏感性、特异性高；在胆胰结合部肿瘤的诊断方面,EUS敏感性、特异性较CT高,与MRCP比较无差异。
结论
1.食道器质性病变以粘膜肌层为主,主要为平滑肌瘤；对粘膜下层的低回声及混合回声病变,需警惕食道结核的存在。
2.胃内的粘膜下隆起性病变以外压性病变为最常见,正常脏器是外压的主要原因。器质性粘膜下病变,胃内主要是间叶源性肿瘤,其次是异位胰腺。超声内镜可以较好地鉴别固有肌层平滑肌瘤和间质瘤。恶性间质瘤相对较大,内部更易出现液化坏死所致的囊性变和钙化。
3.超声内镜是诊断胃内异位胰腺的有效方法,但敏感性不高；超声内镜能为安全有效的内镜下治疗异位胰腺病变提供指导。
4.超声内镜对胆胰结合部病变的诊断有较大的优势。
Objective
To evaluate the effect of endoscopic ultrasonography in diagnosis of gastroenterological leisions and pancreaticobiliary junction lesions.
Methods
Retrospective analyzed the results of2093gastroenterological leisions performed endoscopic ultrasonography from2005January to2009November in a single center.
Results
1. A total1353leisions were included,327leisions were diagnosed pathologically.
2. There were387leisions located at the esophagus, of which149cases,152leisions were diagnoses with pathologically. These diagnosed leisions were mainly leiomyoma from the mucosal of the esophageal wall.
Nine esophageal tuberculosis patients were found that mimic a submucosal tumor under upper endoscopy. Endoscopic ultrasonography showed five patients were with heterogeneous hyperechoic or isoechoic masses and the local wall layers were intact. Two patients were with hypoechoic masses with hyperechoic bands in the parenchyma and the local wall layers were interrupted. Two ulcerative lesions showed hyperechoic interrupted wall layers. A similar echogenic mediastinal lymph node to the near lesion was observed in three patients.
3. In the599gastric patients, EUS found244definitely diagonosised cases;34.43%(84/244) cases of extraluminal compression,47gastrointestinal stromal tumors,18cases of ectopic pancreas,8cases of leiomyoma. The EUS findings confirmed that leiomyomas were smaller than GISTs, and the echo of leiomyoma is similar to the surrounding muclar propria. GISTs had higher echo than the surrounding muclar propria. They were often heterogeneity. When the cut off point was3.9cm, GISTs were tended to be highly malignant.
4. Compared with mesenchymal tumors, ectopic pancreases showed a significant difference in the lesion location, growth pattern, layer of origin, presence of layer disruption, margin, and internal echo (P<0.05). There was no statistical difference in the lesion size and presence of focal anechoic portion.
5. The sensitivity and specialty of EUS are superior to that of ultrasound, CT and MRCP in pancreaticobiliary junction lesions.
Conclusion
EUS is essential in diagnosis and management for gastroenterological leisions. A biliopancreatic EUS has a significant impact on the patient diagnosis.
引文
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1. Bhatia, V., M. Tajika, and A. Rastogi, Upper gastrointestinal submucosal lesions-clinical and endosonographic evaluation and management. Trop Gastroenterol,2010.31(1):p.5-29.
2. Fletcher, C.D., et al., Diagnosis of gastrointestinal stromal tumors:A consensus approach. Hum Pathol,2002.33(5):p.459-65.
3. Kang, J.H., et al., Role of EUS and MDCT in the diagnosis of gastric submucosal tumors according to the revised pathologic concept of gastrointestinal stromal tumors. Eur Radiol,2009.19(4):p.924-34.
4.中国胃肠道间质瘤专家组,中国胃肠道间质瘤诊断治疗共识(2008年版)临床肿瘤学杂志,2009.14(8)：p.746-754.
5. Joensuu, H., Risk stratification of patients diagnosed with gastrointestinal stromal tumor. Hum Pathol,2008.39(10):p.1411-9.
6. Hornick, J.L. and C.D. Fletcher, The role of KIT in the management of patients with gastrointestinal stromal tumors. Hum Pathol,2007.38(5):p.679-87.
7.中国胃肠道间质瘤病理专家组,中国胃肠道间质瘤病理共识意见.中华病理学杂志,2007.36(10)：p.704-706.
8. Chien, C.H., et al., The role of endoscopic ultrasonography examination for evaluation and surveillance of gastric subepithelial masses. Chang Gung Med J, 2010.33(1):p.73-81.
9. Stamatakos, M., et al., Gastrointestinal stromal tumor. World J Surg Oncol, 2009.7:p.61.
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