1、Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,第五章胃癌,（,）,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,講授目的和要求,.,掌握本病的診斷要點,.,熟悉本病的臨床表現(xiàn),.,了解本病的病因、發(fā)病機制,Department of Gastroenterology,The First Affiliated Hospital of Che

2、ngdu Medical College,講授主要內(nèi)容,病因和發(fā)病機制,病理,臨床表現(xiàn),胃鏡檢查,實驗室檢查,線鋇餐,診斷,并發(fā)癥,治療,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,概述,胃癌系來源于胃黏膜上皮的惡性腫瘤，主要是胃腺癌,年新診斷胃癌近萬例，病死人數(shù)萬，占惡性腫瘤診斷的第,位和惡性腫瘤病死率的第位,分布于發(fā)展中國家，地理分布上以日本和中國等東亞國家,為高發(fā),我國北方發(fā)病率高于南方，農(nóng)村高于城市，男性發(fā)病率和,死亡率均高于女性，歲為高發(fā)年齡段,全國平均

3、死亡率約萬（男性萬，女性萬）,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和發(fā)病機制,胃癌的發(fā)生是一個多因素、多步驟進行性發(fā)展的過程,不良環(huán)境、飲食及多種因素作用下，及生長因子,等介導發(fā)生連續(xù)性慢性炎癥，由慢性炎癥萎縮性胃炎萎縮,性胃炎伴腸化異型增生而逐漸向胃癌演變,相關(guān)癌基因、,相關(guān)抑癌基因,:,、,、,、,相關(guān)生長因子,:,、,Department of Gastroenterology,The First Affiliated Hospital of C

4、hengdu Medical College,病因和發(fā)病機制環(huán)境和飲食因素,環(huán)境因素,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,比例失調(diào)、化學污染可參與胃癌的發(fā)生,飲食因素,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，,增加胃癌的危險性,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和發(fā)病機制環(huán)境和飲食因素,食物中硝酸鹽可以被細菌還原成亞硝酸鹽，與胺,結(jié)合生成亞硝胺,胃內(nèi)細

5、菌增加可以促進亞硝酸鹽類致癌物的產(chǎn)生,慢性胃炎、胃部分切除、老年人,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和發(fā)病機制感染因素,與胃癌有共同的流行病學特點,胃癌高發(fā)區(qū)感染,率高,;,抗體陽性人群發(fā)生胃癌的危險性高于陰,性人群,動物實驗示可誘發(fā)胃癌,年國際癌腫研究機構(gòu)將定為類致癌原,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病

6、因和發(fā)病機制感染因素,致胃癌的可能機制,:,、導致的慢性炎癥內(nèi)源性致突變原,胃黏膜萎縮、腸化、不典型增生癌變,、還原亞硝酸鹽，亞硝基化合物是公認的致癌物,、代謝產(chǎn)物促進上皮細胞變異,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和發(fā)病機制感染因素,其他感染因素,病毒,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和發(fā)病機制遺傳因素

7、,胃癌有明顯的家族聚集傾向，家族發(fā)病率高于人群倍,據(jù)歷史記載，拿破侖一家三代人中大多死于胃癌：祖父,死于胃癌；父親死于胃癌；三個妹妹也均患胃癌；他本,人也于年死于胃癌,少數(shù)胃癌屬遺傳性胃癌易感綜合征，浸潤性胃癌有更高的,家族發(fā)病傾向,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和發(fā)病機制癌前狀態(tài),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,癌前病變指易轉(zhuǎn)變成癌組織的病理組織學變化，,主要指異型增生,腸型化生：分小腸型和大腸型,異型增生：胃黏膜腺管結(jié)構(gòu)

8、及上皮細胞失,去正常的狀態(tài)出現(xiàn)異型性改變，組織學上介于良,惡性之間,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病因和發(fā)病機制癌前狀態(tài),腸上皮化生、萎縮性胃炎及異型增生,胃息肉,炎性息肉：多,癌變率低,腺瘤性息肉：癌變率高,特別是,的廣基息肉,胃潰瘍,發(fā)生率約，多因潰瘍邊緣的炎癥、糜爛、再,生及異型增生所致,殘胃炎,畢式胃大部切除術(shù)后年發(fā)生，殘胃癌發(fā),生率約,Department of Gastroenterology,The First Affiliated H

9、ospital of Chengdu Medical College,病理,好發(fā)部位,胃竇,(),、賁門,(),、胃體,(),、全胃或大部,分,胃,(),早期胃癌,病灶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,進展期胃癌,胃癌深度超過黏膜下層，侵及肌層者稱中期胃,癌；侵及漿膜或漿膜外者稱晚期胃癌,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,病理,Department of Gastroenterology,The First Affiliated H

10、ospital of Chengdu Medical College,病理組織病理學,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、印戒細胞,癌、混合性腺癌、腺鱗癌、髓樣癌、肝樣腺癌、,鱗狀細胞癌和未分化癌,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,病理侵襲與轉(zhuǎn)移,直接蔓延,直接侵入鄰近器官，胃底賁門癌常侵犯食管、肝及大網(wǎng),膜，胃體癌則侵犯大網(wǎng)膜、肝及胰腺,淋巴轉(zhuǎn)移,先局部淋巴結(jié)，再到遠處淋巴結(jié)，最常

11、見，淋巴結(jié),血行播散,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,癌細胞脫落入腹腔種植于腸壁和盆腔，如種植于卵巢稱瘤,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,臨床表現(xiàn)癥狀,早期胃癌,多無癥狀，部分患者可有消化不良癥狀,進展期胃癌,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,累及食管下段咽下困難、,幽門梗阻惡心、嘔吐,上消化道出血嘔血或黑糞,胃癌肝轉(zhuǎn)移右上腹痛、黃疸或發(fā)熱,胃癌肺轉(zhuǎn)移咳嗽、呃逆、咯血,胃癌胸膜轉(zhuǎn)移胸腔積

12、液、呼吸困難,胃癌胰腺轉(zhuǎn)移背部反射性疼痛,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,臨床表現(xiàn)體征,早期胃癌,無明顯體征,晚期胃癌,上腹部包塊，上腹壓痛,胃癌肝轉(zhuǎn)移,肝大、黃疸、腹水,胃癌腹膜轉(zhuǎn)移,腹水、移動性濁音,侵犯門靜脈或脾靜脈,脾臟增大,遠處淋巴結(jié)轉(zhuǎn)移,淋巴結(jié),Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,胃鏡結(jié)合黏膜

13、活檢是診斷胃癌最可靠的手段。確診率達,以上,早期胃癌,好發(fā)部位：胃竇及胃體,胃鏡下表現(xiàn)：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,染色胃鏡、放大胃鏡、窄帶光成像和激光共聚焦胃鏡可以,提高診斷率,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,早期胃癌內(nèi)鏡分類法：,型（息肉樣型）：廣基無蒂，常,型（淺表型）：本型最常見，又分三個亞型,型（淺表隆起型）：病變稍高出黏膜，,型（淺表平坦型）：病變表面粗糙呈顆粒狀,型（淺表凹陷型）：凹陷,，底

14、面粗糙,型（潰瘍型）：黏膜糜爛比型深，但不超過,黏膜下層,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,早期胃癌（,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,Department of Gastroenterology,T

15、he First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,早期胃癌（型）：胃竇后壁丘樣隆起，,類圓形、表面少許糜爛，活檢示印戒細胞癌,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,早期胃癌（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)黏液細胞癌,Department of Gastroenterology,The First Affiliated Hospital of

16、Chengdu Medical College,胃鏡檢查,進展期胃癌,胃鏡下表現(xiàn)：,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、無聚合皺襞，病變處無蠕動,流出道狹窄,皮革胃,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,分型法：,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,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,浸潤，與正常黏膜分界不清，最常見,型：又稱彌漫浸潤型

17、，癌發(fā)生于黏膜表層之下，向四,周浸潤擴散，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張的小胃，稱為皮革胃,( ),Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,進展期胃癌（,型）：胃體后壁球,形隆起，表面糜爛不平、伴出血,Department of Gast

18、roenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,進展期胃癌（,型）：胃角巨大癌性潰瘍，,基底不平、厚苔，周邊環(huán)堤樣隆起,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,進展期胃癌（,型）：胃角類圓形潰瘍，,基底不平結(jié)節(jié)狀，病變向周邊浸潤,Department of Gastroenterology,The First Affiliated Hospital

19、of Chengdu Medical College,胃鏡檢查,超聲內(nèi)鏡,可較準確判斷腫瘤侵犯的深度，有助于早期和進,展期癌的區(qū)分,可以了解有無局部淋巴結(jié)轉(zhuǎn)移，作為的補充,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,胃鏡檢查,胃鏡下隆起性包塊，示局限于黏膜下層內(nèi)的低回聲，,病理示腺癌,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,實驗室

20、檢查,貧血,大便隱血陽性,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,線鋇餐,表現(xiàn),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，胃癌可能性大,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,診斷,胃癌的診斷主要依據(jù)胃鏡檢查加活檢,對中上腹痛、消化不良、嘔血或黑糞者及時行胃,鏡檢查,對下列情況應(yīng)定期

21、胃鏡檢查：,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)治療月無效,胃大部切除術(shù)后年以上者,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,并發(fā)癥,出血,多呈嘔血或黑糞、可發(fā)生難治性大出血,賁門或幽門梗阻,進食困難、嘔吐、腹脹及營養(yǎng)不良,穿孔,多見于幽門前區(qū)的潰瘍型癌,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,治療,早期胃癌沒有淋巴

22、結(jié)轉(zhuǎn)移時，可采取內(nèi)鏡治療,進展期胃癌沒有全身轉(zhuǎn)移時，行手術(shù)治療,腫瘤切除后，應(yīng)盡可能清除殘胃的感染,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medical College,治療內(nèi)鏡治療,內(nèi)鏡下黏膜切除術(shù),（,),內(nèi)鏡下黏膜剝離術(shù),（,),適用于高或中分化、無潰瘍、直徑小于且無淋巴,結(jié)轉(zhuǎn)移者,切除組織送病理檢查，發(fā)現(xiàn)癌組織侵襲黏膜下層，,需追加手術(shù)治療,Department of Gastroenterology,The First Affiliated Hospital of Chengdu Medica