第6章 內(nèi)科學(xué)8版-胃癌

1、Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege第五章胃癌第五章胃癌 （gastric gastric cancer cancer）Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospi

2、tal of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege講授目的和要求講授目的和要求1.1.掌握本病的診斷要點掌握本病的診斷要點2.2.熟悉本病的臨床表現(xiàn)熟悉本病的臨床表現(xiàn) 3.3.了解本病的病因、發(fā)病機(jī)制了解本病的病因、發(fā)病機(jī)制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliat

3、ed Hospital of Chengdu Medical CollegeCollege講授主要內(nèi)容講授主要內(nèi)容病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制病理病理臨床表現(xiàn)臨床表現(xiàn)胃鏡檢查胃鏡檢查實驗室實驗室檢查檢查X X線鋇餐線鋇餐診斷診斷并發(fā)癥并發(fā)癥治療治療Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege概述概述

4、胃癌系來源于胃癌系來源于胃黏膜上皮胃黏膜上皮的惡性腫瘤，主要是胃腺癌的惡性腫瘤，主要是胃腺癌20082008年新診斷胃癌近年新診斷胃癌近100100萬例，病死人數(shù)萬例，病死人數(shù)7474萬，占惡性腫萬，占惡性腫瘤診斷的第瘤診斷的第4 4位和惡性腫瘤病死率的第位和惡性腫瘤病死率的第2 2位位2/32/3分布于發(fā)展中國家，地理分布上以分布于發(fā)展中國家，地理分布上以日本日本和和中國中國等東亞等東亞國家為高發(fā)國家為高發(fā)我國我國北方北方發(fā)病率高于發(fā)病率高于南方南方，農(nóng)村農(nóng)村高于高于城市城市，男性發(fā)病率和，男性發(fā)病率和死亡率均高于女性，死亡率均高于女性，55-7055-70歲為高發(fā)年齡段歲為高發(fā)年齡段全國平

5、均死亡率約全國平均死亡率約16/1016/10萬（男性萬（男性21/1021/10萬，女性萬，女性10/1010/10萬）萬）Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和發(fā)病機(jī)制胃癌的發(fā)生是一個多因素、多步驟進(jìn)行性發(fā)展的過程胃癌的發(fā)生是一個多因素、多步驟進(jìn)行性發(fā)展的過程 不良環(huán)境不良環(huán)境、飲食

6、飲食及及HpHp多種因素作用下，多種因素作用下，COX-2COX-2及及生長因子生長因子等介導(dǎo)發(fā)生連續(xù)性慢性炎癥，由等介導(dǎo)發(fā)生連續(xù)性慢性炎癥，由慢性炎癥慢性炎癥- -萎縮性胃炎萎縮性胃炎- -萎萎縮性胃炎伴腸化縮性胃炎伴腸化- -異型增生異型增生- -而逐漸向而逐漸向胃癌胃癌演變演變 相關(guān)癌基因相關(guān)癌基因: :rasras、bcl-2bcl-2、c-mycc-myc 相關(guān)抑癌基因相關(guān)抑癌基因: : p53 p53 、 APC APC 、 DCC DCC 、 MCC MCC 相關(guān)生長因子相關(guān)生長因子: : EGF EGF 、 TGF- TGF- Department of Gastroenter

7、ologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制-環(huán)境和飲食因素環(huán)境和飲食因素環(huán)境因素環(huán)境因素美國的日本移民，胃癌發(fā)病率逐代下降美國的日本移民，胃癌發(fā)病率逐代下降火山巖地帶、高泥碳土壤、水土含硝酸鹽過多、微量元素火山巖地帶、高泥碳土壤、水土含硝酸鹽過多、微量元素比例失調(diào)、化學(xué)污染可參與胃癌的發(fā)生比例失調(diào)、化學(xué)污染可參與胃癌的

8、發(fā)生飲食因素飲食因素多吃新鮮水果和蔬菜可降低胃癌的發(fā)生多吃新鮮水果和蔬菜可降低胃癌的發(fā)生經(jīng)常食用霉變食品、咸菜、腌制煙熏食品以及過多的食鹽，經(jīng)常食用霉變食品、咸菜、腌制煙熏食品以及過多的食鹽，增加胃癌的危險性增加胃癌的危險性Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制-環(huán)

9、境和飲食因素環(huán)境和飲食因素食物中食物中硝酸鹽硝酸鹽可以被細(xì)菌還原成可以被細(xì)菌還原成亞硝酸鹽亞硝酸鹽，與胺，與胺結(jié)合生成結(jié)合生成亞硝胺亞硝胺胃內(nèi)胃內(nèi)細(xì)菌細(xì)菌增加可以促進(jìn)增加可以促進(jìn)亞硝酸鹽類亞硝酸鹽類致癌物的產(chǎn)生致癌物的產(chǎn)生 慢性胃炎慢性胃炎、胃部分切除胃部分切除、老年人老年人Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical Coll

10、egeCollege病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制-感染因素感染因素HpHp Hp Hp與胃癌有共同的流行病學(xué)特點與胃癌有共同的流行病學(xué)特點, , 胃癌高發(fā)區(qū)胃癌高發(fā)區(qū)HpHp感染率感染率高高; ; HpHp抗體陽性人群發(fā)生胃癌的危險性高于陰性人群抗體陽性人群發(fā)生胃癌的危險性高于陰性人群 動物實驗示動物實驗示:Hp:Hp可誘發(fā)胃癌可誘發(fā)胃癌 19941994年國際癌腫研究機(jī)構(gòu)將年國際癌腫研究機(jī)構(gòu)將HpHp定為定為類類致癌原致癌原Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hosp

11、ital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制-感染因素感染因素HpHp致胃癌的可能機(jī)制致胃癌的可能機(jī)制: :1 1、HpHp導(dǎo)致的慢性炎癥導(dǎo)致的慢性炎癥內(nèi)源性致突變原內(nèi)源性致突變原 胃黏膜萎縮、腸化、不典型增生胃黏膜萎縮、腸化、不典型增生癌變癌變2 2、HpHp還原亞硝酸鹽，還原亞硝酸鹽，N N亞硝基化合物是公認(rèn)的致癌物亞硝基化合物是公認(rèn)的致癌物3 3、HpHp代謝產(chǎn)物促進(jìn)上皮細(xì)胞變異代謝產(chǎn)物促進(jìn)上皮細(xì)胞變異Department of G

12、astroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制-感染因素感染因素其他感染因素其他感染因素 EBEB病毒病毒Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengd

13、u Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制-遺傳因素遺傳因素胃癌有明顯的胃癌有明顯的家族聚集傾向家族聚集傾向，家族發(fā)病率高于人群，家族發(fā)病率高于人群2-32-3倍倍 據(jù)歷史記載，拿破侖一家三代人中大多死于胃癌：據(jù)歷史記載，拿破侖一家三代人中大多死于胃癌：祖父祖父死于胃癌；父親死于胃癌；死于胃癌；父親死于胃癌；三個妹妹三個妹妹也均患胃癌；他也均患胃癌；他本本人人也于也于18211821年死于胃癌年死于胃癌少數(shù)胃癌屬遺傳性胃癌易感綜合征，少數(shù)胃癌屬遺傳性胃癌易感綜合征

14、，浸潤性胃癌浸潤性胃癌有更高的有更高的家族發(fā)病傾向家族發(fā)病傾向Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制-癌前狀態(tài)癌前狀態(tài)癌前疾病癌前疾病- -指與胃癌相關(guān)的胃良性疾病，有發(fā)生胃癌的危險指與胃癌相關(guān)的胃良性疾病，有發(fā)生胃癌的危險癌前病變癌前病變指易轉(zhuǎn)變成癌組織的病理組織

15、學(xué)變化，主要指指易轉(zhuǎn)變成癌組織的病理組織學(xué)變化，主要指異型增生異型增生 腸型化生：分小腸型和大腸型腸型化生：分小腸型和大腸型 異型增生：異型增生：胃黏膜腺管結(jié)構(gòu)及上皮細(xì)胞失去正常的狀態(tài)出胃黏膜腺管結(jié)構(gòu)及上皮細(xì)胞失去正常的狀態(tài)出現(xiàn)異型性改變，組織學(xué)上介于良惡性之間現(xiàn)異型性改變，組織學(xué)上介于良惡性之間Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu M

16、edical CollegeCollege病因和發(fā)病機(jī)制病因和發(fā)病機(jī)制-癌前狀態(tài)癌前狀態(tài)腸上皮化生、萎縮性胃炎及異型增生腸上皮化生、萎縮性胃炎及異型增生胃息肉胃息肉 炎性息肉：多炎性息肉：多222cmcm的的廣基息肉廣基息肉胃潰瘍胃潰瘍 發(fā)生率約發(fā)生率約0.5%0.5%2%2%，多因潰瘍邊緣的炎癥、糜爛、再，多因潰瘍邊緣的炎癥、糜爛、再生及異型增生所致生及異型增生所致殘胃炎殘胃炎 畢畢式胃大部切除術(shù)后式胃大部切除術(shù)后10101515年發(fā)生，殘胃癌發(fā)生率年發(fā)生，殘胃癌發(fā)生率約約0.6%0.6%2.5%2.5%Department of GastroenterologyDepartment of

17、GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病理病理好發(fā)部位好發(fā)部位 胃竇胃竇(58%) (58%) 、賁門、賁門(20%) (20%) 、胃體、胃體(15%) (15%) 、全胃或大部、全胃或大部 分胃分胃(7%) (7%) 早期胃癌早期胃癌 病灶病灶局限且深度不超過黏膜下層的胃癌，而不論有無淋局限且深度不超過黏膜下層的胃癌，而不論有無淋巴結(jié)轉(zhuǎn)移巴結(jié)轉(zhuǎn)移進(jìn)展期胃癌進(jìn)展期胃癌 胃癌深度

18、超過黏膜下層，侵及肌層者稱中期胃癌胃癌深度超過黏膜下層，侵及肌層者稱中期胃癌；侵及侵及漿膜或漿膜外漿膜或漿膜外者稱晚期胃癌者稱晚期胃癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病理病理Department of GastroenterologyDepartment of Gastroenterol

19、ogyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病理病理-組織病理學(xué)組織病理學(xué)按腺體的形成及粘液分泌能力又可分為按腺體的形成及粘液分泌能力又可分為 乳頭狀腺癌、管狀腺癌、粘液腺癌、印戒細(xì)胞癌、混合乳頭狀腺癌、管狀腺癌、粘液腺癌、印戒細(xì)胞癌、混合性腺癌、腺鱗癌、髓樣癌、肝樣腺癌、鱗狀細(xì)胞癌和未性腺癌、腺鱗癌、髓樣癌、肝樣腺癌、鱗狀細(xì)胞癌和未分化癌分化癌 按分化程度按分化程度分化良好、分化中等、分化差分化良好、分化中等

20、、分化差Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病理病理-侵襲與轉(zhuǎn)移侵襲與轉(zhuǎn)移直接蔓延直接蔓延 直接侵入鄰近器官，直接侵入鄰近器官，胃底賁門癌胃底賁門癌常侵犯食管、肝及大網(wǎng)常侵犯食管、肝及大網(wǎng)膜，膜，胃體癌胃體癌則侵犯大網(wǎng)膜、肝及胰腺則侵犯大網(wǎng)膜、肝及胰腺淋巴轉(zhuǎn)移淋巴轉(zhuǎn)移 先局部淋巴結(jié)，再到遠(yuǎn)處

21、淋巴結(jié)，最常見，先局部淋巴結(jié)，再到遠(yuǎn)處淋巴結(jié)，最常見，VirchowVirchow淋巴淋巴結(jié)結(jié)血行播散血行播散 以累及肝臟多見，其次肺、腹膜、腎上腺、腎、腦、骨髓以累及肝臟多見，其次肺、腹膜、腎上腺、腎、腦、骨髓腹腔內(nèi)種植腹腔內(nèi)種植癌細(xì)胞脫落入腹腔種植于腸壁和盆腔，癌細(xì)胞脫落入腹腔種植于腸壁和盆腔，如如種植于卵巢稱種植于卵巢稱KrukenbergKrukenberg瘤瘤Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The F

22、irst Affiliated Hospital of Chengdu Medical CollegeCollege臨床表現(xiàn)臨床表現(xiàn)-癥狀癥狀早期胃癌早期胃癌 多無癥狀，部分患者可有消化不良癥狀多無癥狀，部分患者可有消化不良癥狀進(jìn)展期胃癌進(jìn)展期胃癌 上腹痛（餐后加重）、納差、厭食、乏力、體重減輕上腹痛（餐后加重）、納差、厭食、乏力、體重減輕并發(fā)癥或轉(zhuǎn)移癥狀并發(fā)癥或轉(zhuǎn)移癥狀累及食管下段累及食管下段-咽下困難、咽下困難、幽門梗阻幽門梗阻-惡心、嘔吐惡心、嘔吐上消化道出血上消化道出血-嘔血或黑糞嘔血或黑糞胃癌胃癌肝肝轉(zhuǎn)移轉(zhuǎn)移-右上腹痛、黃疸或發(fā)熱右上腹痛、黃疸或發(fā)熱胃癌胃癌肺肺轉(zhuǎn)移轉(zhuǎn)移-咳嗽、呃逆、

23、咯血咳嗽、呃逆、咯血胃癌胃癌胸膜胸膜轉(zhuǎn)移轉(zhuǎn)移胸腔積液、呼吸困難胸腔積液、呼吸困難胃癌胃癌胰腺胰腺轉(zhuǎn)移轉(zhuǎn)移背部反射性疼痛背部反射性疼痛Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege臨床表現(xiàn)臨床表現(xiàn)-體征體征早期胃癌早期胃癌 無明顯體征無明顯體征晚期胃癌晚期胃癌上腹部包塊，上腹壓痛上腹部包塊，上腹壓痛胃癌

24、胃癌肝肝轉(zhuǎn)移轉(zhuǎn)移 肝大、黃疸、腹水肝大、黃疸、腹水胃癌胃癌腹膜腹膜轉(zhuǎn)移轉(zhuǎn)移 腹水、移動性濁音腹水、移動性濁音侵犯門靜脈或脾靜脈侵犯門靜脈或脾靜脈脾臟增大脾臟增大遠(yuǎn)處淋巴結(jié)轉(zhuǎn)移遠(yuǎn)處淋巴結(jié)轉(zhuǎn)移VirchowVirchow淋巴結(jié)淋巴結(jié)Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查胃鏡結(jié)合黏膜

25、活檢是診斷胃癌最可靠的手段。確診率達(dá)胃鏡結(jié)合黏膜活檢是診斷胃癌最可靠的手段。確診率達(dá)95959999% %以上以上早期胃癌早期胃癌 好發(fā)部位：好發(fā)部位：胃竇及胃體胃竇及胃體 胃鏡下表現(xiàn)：胃鏡下表現(xiàn)：息肉樣隆起或凹陷、平坦但黏膜粗糙、觸息肉樣隆起或凹陷、平坦但黏膜粗糙、觸 之易出血，斑片狀充血及糜爛之易出血，斑片狀充血及糜爛染色胃鏡染色胃鏡、放大胃鏡放大胃鏡、窄帶光成像窄帶光成像和和激光共聚焦激光共聚焦胃鏡胃鏡可以提高診斷率可以提高診斷率Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated

26、 Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查早期胃癌內(nèi)鏡分類法：早期胃癌內(nèi)鏡分類法： 型（息肉樣型）：廣基無蒂，常型（息肉樣型）：廣基無蒂，常2cm2cm 型（淺表型）：本型最常見，又分三個亞型型（淺表型）：本型最常見，又分三個亞型 aa型（淺表隆起型）：病變稍高出黏膜，型（淺表隆起型）：病變稍高出黏膜，0.50.5cmcm b b型（淺表平坦型）：病變表面粗糙呈顆粒狀型（淺表平坦型）：病變表面粗糙呈顆粒狀 c c型（淺表凹陷型）：凹陷型（

27、淺表凹陷型）：凹陷0.50.5cmcm，底面粗糙，底面粗糙 型（潰瘍型）：黏膜糜爛比型（潰瘍型）：黏膜糜爛比c c型深，但不超過黏膜下型深，但不超過黏膜下層層Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查Department of GastroenterologyDepartment

28、of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查早期胃癌（早期胃癌（型）：胃角上息肉樣隆起，表面充血、糜爛、型）：胃角上息肉樣隆起，表面充血、糜爛、伴有少許出血，活檢示低分化腺癌，手術(shù)證實為黏膜內(nèi)癌伴有少許出血，活檢示低分化腺癌，手術(shù)證實為黏膜內(nèi)癌Department of GastroenterologyDepartment of GastroenterologyT

29、he First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查早期胃癌（早期胃癌（aa型）：胃竇后壁丘樣隆起，型）：胃竇后壁丘樣隆起，類圓形、表面少許糜爛，活檢示印戒細(xì)胞癌類圓形、表面少許糜爛，活檢示印戒細(xì)胞癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medica

30、l The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查 早期胃癌（早期胃癌（型）：胃竇前壁潰瘍，形不規(guī)則、邊不整型）：胃竇前壁潰瘍，形不規(guī)則、邊不整基底覆以黃白苔，活檢示黏膜內(nèi)黏液細(xì)胞癌基底覆以黃白苔，活檢示黏膜內(nèi)黏液細(xì)胞癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of

31、Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查進(jìn)展期胃癌進(jìn)展期胃癌胃鏡下表現(xiàn)：胃鏡下表現(xiàn)： 腫瘤表面凹凸不平，糜爛，有污穢苔腫瘤表面凹凸不平，糜爛，有污穢苔 深大潰瘍、底部覆有污穢苔，潰瘍邊緣呈結(jié)節(jié)樣隆起、深大潰瘍、底部覆有污穢苔，潰瘍邊緣呈結(jié)節(jié)樣隆起、無聚合皺襞，病變處無蠕動無聚合皺襞，病變處無蠕動 流出道狹窄流出道狹窄 皮革胃皮革胃Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The Fir

32、st Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查 Bormann Bormann分型法：分型法： 型：息肉型，腫瘤向胃腔內(nèi)生長隆起型：息肉型，腫瘤向胃腔內(nèi)生長隆起 型：潰瘍型，單個或多個潰瘍，邊緣隆起，與黏膜分型：潰瘍型，單個或多個潰瘍，邊緣隆起，與黏膜分界清楚界清楚 型：又稱潰瘍浸潤型，隆起而有結(jié)節(jié)狀的邊緣向四周型：又稱潰瘍浸潤型，隆起而有結(jié)節(jié)狀的邊緣向四周浸潤，與正常黏膜分界不清，最常見浸潤，與正常黏膜分界不清，最常見 型：又稱彌漫浸潤型，癌發(fā)生于黏膜表層之下，向四型：又稱彌漫浸潤型，癌發(fā)生于黏膜表層之下，向四

33、周浸潤擴(kuò)散，伴纖維組織增生，少見。如累及全胃，則周浸潤擴(kuò)散，伴纖維組織增生，少見。如累及全胃，則胃變成一固定而不能擴(kuò)張的小胃，稱為皮革胃胃變成一固定而不能擴(kuò)張的小胃，稱為皮革胃( (linitis linitis plasticaplastica) )Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡

34、檢查胃鏡檢查Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查進(jìn)展期胃癌（進(jìn)展期胃癌（型）：胃體后壁球型）：胃體后壁球形隆起，表面糜爛不平、伴出血形隆起，表面糜爛不平、伴出血Department of GastroenterologyDepartment of Gastroenterolo

35、gyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查進(jìn)展期胃癌（進(jìn)展期胃癌（型）：胃角巨大癌性潰瘍，型）：胃角巨大癌性潰瘍，基底不平、厚苔，周邊環(huán)堤樣隆起基底不平、厚苔，周邊環(huán)堤樣隆起Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The

36、 First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查進(jìn)展期胃癌（進(jìn)展期胃癌（型）：胃角類圓形潰瘍，型）：胃角類圓形潰瘍，基底不平結(jié)節(jié)狀，病變向周邊浸潤基底不平結(jié)節(jié)狀，病變向周邊浸潤Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCol

37、lege胃鏡檢查胃鏡檢查超聲內(nèi)鏡超聲內(nèi)鏡 可較準(zhǔn)確判斷腫瘤侵犯的深度，有助于早期和進(jìn)展期癌可較準(zhǔn)確判斷腫瘤侵犯的深度，有助于早期和進(jìn)展期癌的區(qū)分的區(qū)分 可以了解有無局部淋巴結(jié)轉(zhuǎn)移，作為可以了解有無局部淋巴結(jié)轉(zhuǎn)移，作為CTCT的補充的補充Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃鏡檢查胃鏡檢查胃鏡

38、下胃鏡下2.5cm隆起性包塊，隆起性包塊，EUS示局限于黏膜下層內(nèi)的示局限于黏膜下層內(nèi)的低回聲，病理示腺癌低回聲，病理示腺癌Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege實驗室檢查貧血貧血大便隱血陽性大便隱血陽性Department of GastroenterologyDepartment of G

39、astroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollegeX X線鋇餐線鋇餐表現(xiàn)表現(xiàn)龕影或充盈缺損，難以區(qū)分良惡性龕影或充盈缺損，難以區(qū)分良惡性黏膜皺襞破壞、消失或中斷，臨近胃黏膜僵直，蠕動消失，黏膜皺襞破壞、消失或中斷，臨近胃黏膜僵直，蠕動消失，胃癌可能性大胃癌可能性大Department of GastroenterologyDepartment of GastroenterologyThe Fi

40、rst Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege診斷診斷胃癌的診斷主要依據(jù)胃鏡檢查加活檢胃癌的診斷主要依據(jù)胃鏡檢查加活檢對對中上腹痛中上腹痛、消化不良消化不良、嘔血嘔血或或黑糞黑糞者及時行胃者及時行胃鏡檢查鏡檢查對下列情況應(yīng)定期胃鏡檢查：對下列情況應(yīng)定期胃鏡檢查： 慢性萎縮性胃炎伴腸化生或異型增生者慢性萎縮性胃炎伴腸化生或異型增生者 胃潰瘍經(jīng)正規(guī)治療胃潰瘍經(jīng)正規(guī)治療2 2月無效月無效 胃大部切除術(shù)后胃大部切除術(shù)后1010年以上者年以

41、上者Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege并發(fā)癥出血出血多呈嘔血或黑糞、多呈嘔血或黑糞、5%5%可發(fā)生難治性大出血可發(fā)生難治性大出血賁門或幽門梗阻賁門或幽門梗阻進(jìn)食困難、嘔吐、腹脹及營養(yǎng)不良進(jìn)食困難、嘔吐、腹脹及營養(yǎng)不良 穿孔穿孔 多見于幽門前區(qū)的潰瘍型癌多見于幽門前區(qū)的潰瘍型癌Departm

42、ent of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治療治療早期胃癌早期胃癌沒有淋巴結(jié)轉(zhuǎn)移時，可采取沒有淋巴結(jié)轉(zhuǎn)移時，可采取內(nèi)鏡治療內(nèi)鏡治療進(jìn)展期胃癌進(jìn)展期胃癌沒有全身轉(zhuǎn)移時，行沒有全身轉(zhuǎn)移時，行手術(shù)治療手術(shù)治療腫瘤切除后，應(yīng)盡可能清除殘胃的腫瘤切除后，應(yīng)盡可能清除殘胃的HpHp感染感染Department of Gas

43、troenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治療-內(nèi)鏡治療內(nèi)鏡下黏膜切除術(shù)內(nèi)鏡下黏膜切除術(shù) EMREMR（endoscopic mucosal resection)endoscopic mucosal resection)內(nèi)鏡下黏膜剝離術(shù)內(nèi)鏡下黏膜剝離術(shù) ESDESD（endoscopic submucosalendoscopic submucosal dissection) dissection) 適用于高或中分化、無潰瘍、直徑小于適用于高或中分化、無潰瘍、直徑小于2cm2cm且無淋巴結(jié)轉(zhuǎn)且無淋巴結(jié)轉(zhuǎn)移者移者切除組織送病理檢查，發(fā)現(xiàn)癌組織侵襲黏膜下層，需追加切除組織送病理檢查，發(fā)現(xiàn)癌組織侵襲黏膜下層，需追加手術(shù)治療手術(shù)治療Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of C