2017年 · 第37卷第01期

Seasons are flowing, time flies, and in the blink of an eye it is the end of the year and the beginning of the year. Looking back at 2016, which has just passed, with the support and care of readers and authors, and the joint efforts of all editors and reviewers, China Digestion Magazine not only successfully completed the annual reporting plan, but also gained a lot of achievements and honors. On this occasion of farewell to the old and welcoming the new, we sincerely thank the authors and readers who have been caring and supporting this journal for a long time! I wish you all a Happy New Year and all the best!

More than 90% of pancreatic cancers are ductal adenocarcinoma, which is highly malignant, difficult to diagnose early, and extremely poor prognosis. It is estimated that by 2030, pancreatic cancer will become the second leading tumor killer in humans after lung cancer^[1]。 Compared with other tumors, such as lung cancer and breast cancer, there are already a variety of "precision" targeted therapeutic drugs. The clinical treatment of pancreatic cancer is still in the "non-precision" era. The widely used gemcitabine regimen has an effective rate of only 30%. The chemotherapy regimen of 5-fluorouracil, calcium leucovorin, irinotecan and oxaliplatin (FOLFIRINOX regimen) has large adverse reactions, while the only targeted drug that reflects precision therapy, erlotinib, has limited efficacy^[2]。 Therefore, how to achieve "accurate" diagnosis and treatment of pancreatic cancer is a hot issue in clinical and basic research at present. From the perspectives of genotyping, pathogenesis and therapeutic targets of pancreatic cancer, the possibility of accurate treatment of pancreatic cancer in the future is discussed. How to face the general trend of precision medicine and the opportunities and challenges faced by precision treatment of pancreatic cancer are questions worth considering by clinicians.

The early diagnosis of pancreatic cancer is difficult, the progress is fast, and the prognosis is poor. The median survival time is only 4 to 6 months, and the 5-year survival rate is only about 5%. It is known as the king of cancers. Many countries and regions have successively formulated expert consensus and diagnosis and treatment guidelines for pancreatic cancer, and discussed a variety of surgical, radiochemical treatment options, and the therapeutic effects of biological agents on pancreatic cancer. However, the early diagnosis of pancreatic cancer is difficult, the alarm symptoms are atypical, the specificity of tumor markers is not high, and 80% of pancreatic cancer patients are advanced and cannot be operated at the time of consultation^[1]。 Therefore, pancreatic cancer has become a major problem in clinical diagnosis and treatment.

The role of multi-disciplinary team (MDT) in clinical diagnosis and treatment has been recognized and gradually widely used. It is the mainstream model of comprehensive diagnosis and treatment of pancreatic adenocarcinoma today^[1]。 Patients with pancreatic cancer should be treated in large-scale medical centers, including surgery, digestion, oncology, imaging, endoscopy, pathology, intervention, radiotherapy and other disciplines. The purpose is to make early diagnosis. According to the patient's basic condition, clinical manifestations, tumor stage and pathological type, the diagnosis and treatment plan is formulated after discussion by MDT, and it runs throughout the course of pancreatic cancer. This paper briefly discusses the significance of MDT in the diagnosis and treatment of pancreatic cancer and the role played by gastroenterologists in it.

Pancreatic cancer is one of the common malignant tumors of the digestive system with high mortality rate. Diabetes is a group of metabolic abnormalities in which blood sugar increases due to absolute or relative insulin deficiency. As early as 120 years ago, the close relationship between pancreatic cancer and diabetes has been paid attention to^[1]。 Diabetes and pancreatic cancer have a two-way interaction, and the relationship is complex. On the one hand, diabetes may promote the occurrence of pancreatic cancer, and on the other hand, pancreatic cancer may also induce diabetes. A large number of epidemiological, clinical and molecular mechanism research have made people have a further understanding of the relationship between diabetes and pancreatic cancer. The research progress of the relationship between the two is described as follows.

Acute pancreatitis during pregnancy is a relatively rare complication of pregnancy, which seriously endangers the health of pregnant women, fetuses and newborns. In recent years, with the increase of hyperlipidemia population, acute pancreatitis during pregnancy has also increased. Because there are more concerns about medication during pregnancy, it is more difficult to treat acute pancreatitis during pregnancy than acute pancreatitis in the general population. Twelve patients with acute pancreatitis during pregnancy admitted to Peking University First Hospital in recent years were retrospectively analyzed, and their diagnosis and treatment were summarized. Among these 12 patients, 6 patients were treated for pancreatitis in the internal medicine department and waited for full-term delivery of pregnancy. Many of them had severe cases with a large amount of drugs, which is worth exploring.

nonalcoholic fatty liver disease (NAFLD) is a clinicopathological syndrome, which is mainly characterized by diffuse hepatocellular bullous steatosis, except for ethanol and other definite liver damaging factors. Recent studies have suggested that,H.pyloriInfection may cause NAFLD, but there is no definitive evidence and the mechanism is unknown^[1,2]。 This study is intended to analyzeH.pyloriRelationship between infection and NAFLD.

Hepatocellular carcinoma is one of the common malignant tumors in China, with limited clinical treatment and poor prognosis. Partial liver resection is considered to be the preferred treatment for hepatocellular carcinoma, but its long-term efficacy is not ideal due to the high postoperative recurrence and metastasis rate, so it is necessary to develop new treatment strategies^[1,2,3]。 An in-depth understanding of the complex network of hepatocellular carcinoma metastases is a prerequisite for the development of effective therapeutic approaches. Survival of tumor cells in systemic circulation and migration to distant target organs is a key biological process of tumor metastasis. Anapoptosis is a kind of isolation-induced apoptosis. Anapoptosis tolerance allows some tumor cells to survive in the systemic circulation, which eventually leads to tumor metastasis^[4]。 Multiple abnormally highly active signaling pathways, including integrin signaling pathways, have been shown to prevent anorexia apoptosis in tumor cells^[5,6]。 Recent studies have shown that abnormally highly activated integrins play a key role in metastasis of human hepatocellular carcinoma cells^[7]While integrin alpha 5 is an important member of the integrin family. Cysteine-containing cysteinyl aspartate specific proteinase (caspase) 3 also plays an important role in the process of apoptosis^[8]。 There are few in-depth research reports on the mechanism of action of integrin α 5 in hepatocellular carcinoma metastasis. This study aimed to investigate the relationship between the expression levels of integrin α 5 and caspase3 in hepatocellular carcinoma and clinicopathological features.

With the popularization of endoscopy, the detection rate of cardia, stomach and duodenal polyps is gradually increasing, but the exact etiology and pathogenesis of polyps are still unknown. Some scholars have reported that bile acids may be directly related to the occurrence and development of colon and rectal polyps and adenomas^[1]。 However, the relationship between bile acids and cardia, stomach and duodenal polyps is still unclear. This study aims to investigate the effects of bile reflux on the formation of cardia, stomach and duodenal polyps by endoscopic and pathological examinations.

Pancreatic pseudocyst is one of the common complications of acute and chronic pancreatitis. Its formation is caused by rupture of pancreatic parenchyma or pancreatic duct, leaked pancreatic juice and necrotic tissue accumulate around the pancreas, and the surrounding tissues are stimulated by inflammation to form fibrous cysts without epithelial cells. Pancreatic pseudocyst often occurs in the body and tail of the pancreas. Because of the narrow retroperitoneal space, when the cyst is large in volume, the boundary with the surrounding tissue structure is unclear, and it is difficult to distinguish its tissue source. It is easy to be misdiagnosed as renal cyst or cystic tumor of the retroperitoneal space. The medical records of a patient with chronic pancreatitis complicated with giant pseudocyst of pancreatic tail admitted to the First Affiliated Hospital of Nanchang University were retrospectively analyzed, and the diagnosis and treatment were discussed.

The 81-year-old male was admitted to the hospital on March 4, 2014 due to intermittent upper abdominal distension for more than 1 month. The patient underwent gastroscopy in an external hospital, which showed that there was irregular shallow erosion with a maximum diameter of 2.0 cm in the gastric antrum, covered with mucous white coating, the surface was rough and granular, the texture was brittle, spontaneous bleeding was visible, and residual mucosal islands were visible in the central part (FIG. 1A), diagnosed as: ① gastric antrum erosion (nature to be determined); ② Chronic atrophic gastritis. Pathological biopsy revealed moderately differentiated adenocarcinoma. Endoscopic ultrasound examination indicated that the lesions were limited to mucosa and submucosa, and early cancer was possible. After completing the preoperative routine examination, endoscopic submucosal dissection (ESD) was performed under intravenous anesthesia. During the operation, the edge of the lesion was marked with Dual knife, and the mixture of methylene blue, epinephrine and 0.9% NaCl solution was injected submucosally to fully bulge the lesion. The lesion was incised at 0.5 cm of the marked edge, and the submucosa was stripped layer by layer with Flush knife to completely strip the lesion. The hemostatic forceps electrocoagulated the naked blood vessels on the wound surface (FIG. 1B), the tissue was removed and sent for pathological examination. The whole operation took 1 h 10 min. During the withdrawal, the patient had a choking reaction, and a mucosal tear about 6 cm long was seen from the cardia to the small curve of the upper part of the stomach body, and active bleeding was seen (Figure 1C), placing a titanium clip to clamp the mucosal tear site (Figure 1D), observe no active hemorrhage retrograde mirror. Acid suppression, antibiotics and other treatments were routinely applied postoperatively. The patient did not complain of other discomfort and was discharged 3 days later.

A 61-year-old female was admitted to the hospital in April 2013 due to "diarrhea for 1 month". Combined with the pigmentation of his hands, atrophy and shedding of nails, and multiple polyps in gastrointestinal tract (pathological examination was hyperplastic polyps), he was diagnosed as Canada-Cronkhite syndrome (CCS). For details, see the literature [1]。 At that time, the patient underwent colonoscopy and found a huge lobulated polyp in the transverse colon with bright red surface. He was treated with acid suppression, intestinal flora regulation, water and electrolyte disorder correction, etc. No glucocorticoids, immunosuppressants, nutritional support or polypectomy were used. After 2 weeks, the patient's diarrhea was relieved and he was discharged. After discharge, the patient was not treated with drugs. After a telephone return visit 2 months later, the patient's diarrhea symptoms were further alleviated, but his hair fell out, and no diagnosis and treatment were performed. After 5 months, the patient's diarrhea stopped and hair loss decreased. After 10 months, the patient's hair regrows and new nails grow in both hands. Thereafter, the patient was followed up by telephone every 3 months, and the patient's condition was stable without special discomfort. In September 2015, the patient underwent physical examination after admission due to lower limb trauma: the distribution of hair, eyebrows and body hair was normal, the melanin deposition in both hands disappeared, the skin color returned to normal, and the shape and color of nails (toes) were normal. Laboratory tests: Blood routine, urine routine, fecal routine, liver and kidney function, tumor markers and other tests were normal. Gastroscopy: gastric fundus mucosa normal, vesicular polyps disappeared (Figure 1)； The mosaic-like congestive plaques on the gastric body completely disappeared, and the diffuse wide-base polyps disappeared. Only a flat polyp of about 0.6 cm ×0.8 cm could be seen on the posterior wall of the great curvature of the gastric body (Figure 2)； The congested and swollen thick folds in the gastric antrum disappeared, and the diffusely distributed broad-based polyps disappeared (Figure 3)。 Colonoscopy: Two polyps with a maximum diameter of about 0.5 cm were seen in the descending colon, and the rest of the colorectal mucosa was completely normal. The giant polyps in the transverse colon found in 2013 completely disappeared (Figure 4)。

Common pancreatic diseases mainly include acute and chronic pancreatitis and benign and malignant pancreatic tumors caused by various causes. The common causes of acute and chronic pancreatitis include biliary tract disease, ethanol, hyperlipidemia, genetic factors, immune factors, drugs, idiopathic, etc. The risk factors related to the occurrence and development of pancreatic cancer include long-term smoking, various chronic pancreatitis, obesity, diabetes, genetic factors and so on. However, there are still some pancreatic diseases that have not yet found the exact cause. In recent years, with theH.pyloriIt is also closely related to the occurrence of a variety of parenteral diseases, including iron deficiency anemia, idiopathic thrombocytopenic purpura and urticaria^[1]。 At present, many studies have also discussedH.pyloriCorrelation between infection and pancreatic diseases, including pancreatic cancer, autoimmune pancreatitis, etc.^{[2,3,4,5,6,7,8,9]}But the results are not exactly consistent. Currently, with regard toH.pyloriThe possible role of infection in pancreatic disease remains highly controversial. Now targetingH.pyloriThe correlation between infection and pancreatic disease is briefly reviewed.

acute pancreatitis (AP) refers to the activation of pancreatic enzymes in the pancreas caused by various etiologies, with or without changes in other organ functions. In China, the incidence of AP is increasing year by year, especially the proportion of severe acute pancreatitis (SAP) is increasing. In 2012, the New Atlanta Standard classifies AP into mild, moderately severe and severe, of which SAP accounts for 20% to 30%, and the mortality rate is as high as 36% to 50%. The clinical process is dangerous^[1]。 Therefore, early prediction of AP severity and timely screening of disease changes, especially SAP patients, are crucial to reduce case mortality, shorten hospital stay and reduce economic burden^[2]。 There are many methods to assess the severity of AP in clinic, such as clinical manifestations, scoring system and related serological predictive indicators, etc. In recent years, new predictive methods have emerged on this basis. The following is a review of the research status of early assessment methods of AP.

IBD is a chronic nonspecific intestinal inflammatory reactive disease of unknown etiology, including UC and CD. As a chronic intestinal destructive disease with long course and recurrent episodes, its therapeutic goal has been controversial. For a long time, clinical remission, mucosal healing, deep remission, prevention and treatment of complications and improvement of quality of life have been considered as the ultimate goals of IBD treatment. With the continuous progress of IBD diagnosis and treatment technology, especially the use of new drugs, the treatment goals of IBD are becoming more and more perfect. As a new therapeutic goal, tissue healing can more fully reflect the healing of intestinal mucosa, and it is expected to become the ultimate goal of IBD treatment in the future.