殷桂香 王貞彪 喬進(jìn)朋 魯力峰 王曉燕

[摘要] 目的: 探討雙重染色內(nèi)鏡在消化道早癌中的診斷價(jià)值。方法：選取2009年1月~2010年12月間在豐臺(tái)醫(yī)院消化內(nèi)鏡中心進(jìn)行胃腸鏡檢查的患者1 880例，分為觀察組（406例）和對(duì)照組（1 474例），其中觀察組進(jìn)行內(nèi)鏡下醋酸-盧戈碘液、醋酸-美蘭的雙重染色，并行病理檢查；對(duì)照組采取經(jīng)驗(yàn)性活檢取材病理檢查，觀察兩組差異性。結(jié)果：觀察組中，食管黏膜染色213例，總檢出率為15.5%，早癌4例，中重度非典型增生及食管早癌檢出率為8.0%；對(duì)照組588例，總檢出率3.1%，中重度非典型增生及食管早癌檢出率為1.2%，兩組比較差異有高度統(tǒng)計(jì)學(xué)意義（P＜0.01）；觀察組胃黏膜染色109例，總檢出率66.1%，早癌7例，中重度非典型增生及早期胃癌檢出率為24.8%，對(duì)照組548例，總檢出率8.6%，中重度非典型增生及早期胃癌檢出率為1.6%，兩組比較差異有高度統(tǒng)計(jì)學(xué)意義（P＜0.01）；觀察組腸黏膜染色84例，總檢出率79.8%，早癌1例，中重度非典型增生及結(jié)直腸早癌檢出率為10.7%，對(duì)照組338例，總檢出率19.8%，中重度非典型增生及結(jié)直腸早癌檢出率為0.6%，兩組比較差異有高度統(tǒng)計(jì)學(xué)意義（P＜0.01）。結(jié)論：內(nèi)鏡下醋酸-盧戈碘液、醋酸-美蘭的雙重染色法可提高消化道早癌及癌前病變的檢出率，具有較高應(yīng)用價(jià)值。

[關(guān)鍵詞] 色素內(nèi)鏡；早癌；消化道

[中圖分類號(hào)] R735 [文獻(xiàn)標(biāo)識(shí)碼]B[文章編號(hào)]1673-7210（2011）11（c）-186-03

Important value of double staining endoscopy in diagnosis of early digestive tract cancer

YIN Guixiang1, WANG Zhenbiao2*, QIAO Jinpeng1, LU Lifeng1, WANG Xiaoyan1

1.Department of Gastroenterology, Beijing Fengtai Hospital, Beijng100071, China;2.Department of Gastroenterology, Beijing You'an Hospital Affiliated to Capital University, Beijing100069, China

[Abstract] Objective: To investigate the value of double staining endoscopy in the diagnosis of early digestive tract cancer. Methods: 1 880 patients who had received gastrointestinal endoscopy examination in the digestive endoscopy center of Fengtai hospital from January 2009 to December 2010 were selected and divided into the observation group (406 patients) and the control group (1 474 patients). The observation group received the endoscopic double staining of acetic acid-Lugol's iodine solution and acetic acid-methylene blue and parallel pathological examination, while the control group received empirical biopsy pathological examination. The differences between the two groups were observed. Results: In the observation group, there were 213 patients with esophageal mucosal staining and the total detection rate was 15.5%. There were 4 patients with early cancer and the detection rate of moderate and severe atypical hyperplasia and esophageal early cancer was 8.0%. In the control group, there were 588 patients with esophageal mucosal staining and the total detection rate was 3.1%. The detection rate of moderate and severe atypical hyperplasia and esophageal early cancer was 1.2%. There were significant differences between the observation group and the control group (P<0.01). In the observation group, there were 109 patients with gastric mucosal staining and the total detection rate was 66.1%. There were 7 patients with early cancer and the detection rate of moderate and severe atypical hyperplasia and early gastric cancer was 24.8%. In the control group, there were 548 patients with gastric mucosal staining and the total detection rate was 8.6%. The detection rate of moderate and severe atypical hyperplasia and early gastric cancer was 1.6%. There were significant differences between the observation group and the control group (P<0.01). In the observation group, there were 84 patients with intestinal mucosal staining and the total detection rate was 79.8%. There was 1 patient with early cancer and the detection rate of moderate and severe atypical hyperplasia and colon and rectal early cancer was 10.7%. In the control group, there were 338 patients with intestinal mucosal staining and the total detection rate was 19.8%. The detection rate of moderate and severe atypical hyperplasia and colon and rectal early cancer was 0.6%. There were significant differences between the observation group and the control group (P<0.01). Conclusion: The endoscopic double staining of acetic acid-Lugol's iodine solution and acetic acid-methylene blue can improve the detection rate of digestive tract early cancer and precancerosis, thereby of high application value.

[Key words] Pigment endoscopy; Early cancer; Digestive tract

染色法內(nèi)鏡（chromoendoscopy）又稱色素內(nèi)鏡，應(yīng)用于臨床已有40余年歷史。該項(xiàng)技術(shù)對(duì)早期消化道腫瘤的診斷價(jià)值明顯優(yōu)于普通內(nèi)鏡檢查[1]，國內(nèi)多應(yīng)用單一染色劑染色，作者在內(nèi)鏡檢查過程中進(jìn)行醋酸-盧戈碘液、醋酸-美蘭的雙重染色，與同期普通內(nèi)鏡檢查比較分析，探討雙重染色內(nèi)鏡在消化道早癌中的診斷價(jià)值，現(xiàn)報(bào)道如下：

1 資料與方法

1.1 一般資料

2009年1月~2010年12月在豐臺(tái)醫(yī)院消化內(nèi)鏡中心進(jìn)行胃腸鏡檢查的患者1 880例，分成觀察組和對(duì)照組，觀察組406例，男257例，女149例；年齡24~83歲，平均55.6歲；其中，胃鏡322例，腸鏡84例。對(duì)照組1 474例，男835例，女639例；年齡18~82歲，平均50.2歲；胃鏡1136例，腸鏡338例。除外進(jìn)展期癌、潰瘍、平滑肌瘤等，在常規(guī)檢查發(fā)現(xiàn)可疑病灶（消化道黏膜有隆起、糜爛、粗糙不平、顏色改變）的同時(shí)，觀察組進(jìn)行內(nèi)鏡下雙重染色，并行病理檢查，對(duì)照組采取經(jīng)驗(yàn)性活檢取材病理檢查，觀察兩組差異性。

1.2 方法

采用Olympus GIF/CF 240型電子胃/腸鏡，檢查發(fā)現(xiàn)病變后，于活檢孔插入噴灑管接近病變，直視下先予生理鹽水沖洗并吸引至黏膜表面清潔無黏液附著后噴灑2%醋酸溶液20 ml，1 min后以生理鹽水沖洗，觀察攝片，再予1.25%盧戈碘液（食道）或0.5%美蘭（胃、結(jié)直腸）20 ml噴灑，1 min后以0.9%生理鹽水沖洗，觀察攝片，于病變顯露部位取病理檢查。

1.3 統(tǒng)計(jì)學(xué)處理

采用SPSS 13.0統(tǒng)計(jì)軟件分析，計(jì)數(shù)資料采用χ2檢驗(yàn)，P<0.05為差異有統(tǒng)計(jì)學(xué)意義。

2 結(jié)果

觀察組406例染色病例中，食管黏膜染色213例，兩組食管黏膜病變檢出情況見表1。于淺染區(qū)取活檢，病理報(bào)告食管炎22例，于不染區(qū)取活檢，病理報(bào)告Barrett食管7例，早癌4例，總檢出率15.5%，與對(duì)照組比較有顯著差異（P＜0.01）。觀察組中重度非典型增生及食管早癌檢出率為8.0%，對(duì)照組為1.2%，兩組比較差異有高度統(tǒng)計(jì)學(xué)意義（P＜0.01）。

胃黏膜染色109例，兩組胃黏膜病變檢出情況見表2。異常著色區(qū)域中，于著淡藍(lán)色病變?nèi)』顧z病理報(bào)告萎縮/腸化生23例，輕度不典型增生22例；中度不典型增生15例，于著深藍(lán)病變?nèi)』顧z病理報(bào)告重度不典型增生5例，早癌7例，總檢出率66.1%。與對(duì)照組比較有顯著差異（P＜0.01）。觀察組中重度非典型增生及早期胃癌檢出率為24.8%，對(duì)照組為1.6%，兩組比較差異有高度統(tǒng)計(jì)學(xué)意義（P＜0.01）。

腸黏膜染色84例，兩組腸黏膜病變檢出情況見表3。于腫脹深染區(qū)域取活檢病理報(bào)告腺瘤性息肉38例，輕度非典型增生20例，中度非典型增生3例，重度非典型增生5例，早癌1例，總檢出率79.8%。與對(duì)照組比較有顯著差異（P＜0.01）。觀察組中重度非典型增生及結(jié)直腸早癌檢出率為10.7%，對(duì)照組為0.6%，兩組比較差異有高度統(tǒng)計(jì)這意義（P＜0.01）。

3 討論

消化道早期癌癥是指癌組織局限于黏膜下層以內(nèi)，未累及固有肌層，包括黏膜內(nèi)癌和黏膜下癌，而癌前病變主要指中重度不典型增生。消化道早癌由于病灶微小，普通內(nèi)鏡不易發(fā)現(xiàn)，容易漏診和誤診，因此，如何早期發(fā)現(xiàn)至關(guān)重要。色素內(nèi)鏡的應(yīng)用彌補(bǔ)了普通內(nèi)鏡的不足，染色后對(duì)小病灶的檢出率可比常規(guī)方法提高2~3倍[2]，達(dá)到早期診斷及治療的目的。其原理是在一般內(nèi)鏡觀察時(shí)輔助使用各種色素，從而使病變的形態(tài)及范圍更清晰，繼而有針對(duì)性地活檢，以提高病變檢出率。目前常用的染色劑有盧戈液、美蘭、靛胭脂等。

盧戈碘液是診斷食管癌常用的色素之一。正常食管鱗狀上皮內(nèi)含有豐富的糖原，遇碘呈棕褐色，而柱狀上皮則不染色。因食管癌細(xì)胞內(nèi)糖原含量減少甚至消失，遇碘則呈淡染或不染色；不典型增生病灶的糖原含量減少，呈現(xiàn)不同程度的淡染。美蘭正常黏膜不吸收，但可被糜爛、潰瘍和癌組織吸收染成藍(lán)色，可清楚地顯示黏膜微細(xì)變化，常用于胃、結(jié)腸病變的診斷[3]。

單一色素法有其局限性， 由于染色劑濃度不一、噴灑方法不當(dāng)、個(gè)體差異等因素， 可出現(xiàn)病變處染色深淺、定位不準(zhǔn)確或病變遺漏等。作者通過臨床觀察發(fā)現(xiàn)應(yīng)用新型染色劑醋酸進(jìn)行食管、胃及結(jié)直腸的黏膜染色，可使病變明顯顯露，再配合盧戈碘液、美蘭染色，病變形態(tài)及范圍更趨清晰，從而提高診斷準(zhǔn)確率。

醋酸噴灑胃黏膜后，細(xì)胞內(nèi)pH下降，出現(xiàn)暫時(shí)性脫水，異常的核漿比例顯現(xiàn)出來，細(xì)胞核妨礙光線傳導(dǎo)，表現(xiàn)為上皮變白，2~3 min恢復(fù)原色。反應(yīng)的強(qiáng)弱與細(xì)胞核內(nèi)染色質(zhì)的多少有關(guān)[4-5]。由于不正常上皮細(xì)胞核容量增加，因此，黏膜不典型增生區(qū)域得以顯現(xiàn)。早期大腸癌的內(nèi)鏡下表現(xiàn)多樣，隆起性的腺瘤癌變內(nèi)鏡下較易發(fā)現(xiàn)，而扁平型病變（Ⅱ型病變）內(nèi)鏡下則較易遺漏[6]，俞力等[7]發(fā)現(xiàn)醋酸噴灑可增加全結(jié)腸隆起病變的檢出率。

本組研究通過內(nèi)鏡下醋酸-盧戈碘液、醋酸-美蘭的雙重染色法，對(duì)可疑病變進(jìn)行病理活檢，結(jié)果食管中重度非典型增生及早癌檢出率為8.0%，胃中重度非典型增生及早期癌檢出率為24.8%，結(jié)直腸中重度非典型增生及早癌檢出率為10.7%，明顯高出對(duì)照組。提示醋酸-盧戈碘液、醋酸-美蘭的雙重染色法可提高消化道早癌及癌前病變的檢出率，與文獻(xiàn)[8]報(bào)道一致。

本組12例消化道早癌中9例內(nèi)鏡下表現(xiàn)黏膜紅斑，微凹陷或凹凸不平的糜爛灶，經(jīng)醋酸染色后病變邊緣明顯腫脹隆起，中央凹陷，再經(jīng)盧戈液或美蘭染色后，凹凸面對(duì)比顯著。3例內(nèi)鏡下表現(xiàn)為微隆起病變，經(jīng)醋酸染色后腫脹明顯，邊界清晰，再經(jīng)美蘭染色后，黏膜表面腺體結(jié)構(gòu)趨顯，可清晰地觀察腺管開口形態(tài)。

內(nèi)鏡下醋酸-盧戈碘液、醋酸-美蘭的雙重染色方法簡便，可提高消化道早癌及癌前病變的診斷率，具有較高應(yīng)用價(jià)值，值得臨床推廣應(yīng)用。

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（收稿日期：2011-05-12）