2018年 · 第38卷第03期

Gastric cancer is a common malignant tumor. Although the incidence and prevalence of gastric cancer in China have decreased in recent years, it is still at a high position. The latest epidemiological survey data show that the incidence and mortality of gastric cancer in men rank second and third among all malignant tumors in China, while that in women rank fifth and second^[1]。 According to the 2014 WHO Cancer Report, in 2012, the global incidence of gastric cancer ranked 4th to 5th among all malignant tumors, and the number of deaths was 723,000 (ranking 3rd among all malignant tumors). The annual incidence and death of gastric cancer in China accounts for about 50% of the global total^[1]。 The diagnosis rate of early gastric cancer in China is far lower than that in Japan and South Korea. Most of the clinically found gastric cancers are in the middle and late stages, and the curative effect is not good. Therefore, early warning, early diagnosis and early prevention are very important.

The incidence of gastric cancer in China ranks among the highest in the world. Early diagnosis is of great significance to reduce the mortality rate and improve the prognosis of gastric cancer patients, and gastroscopy is an accurate method to detect and diagnose gastric cancer early. In the past ten years, with the development of endoscopic minimally invasive resection techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, it has become possible to cure early gastric cancer under endoscopy, which has greatly improved the quality of life of patients. However, at present, the overall detection rate of early gastric cancer under digestive endoscopy in China is still relatively low, and the situation of "emphasizing treatment and neglecting diagnosis" in clinical work is not uncommon. The knowledge of how to detect and diagnose early gastric cancer in endoscopic operation needs to be further popularized. In fact, endoscopy-related technologies for the purpose of improving the diagnostic ability of early cancer and microcarcinoma under endoscopy have been developing rapidly, from staining endoscopy in the 20th century to high-definition endoscopy, magnification endoscopy, image enhancement endoscopy, laser confocal endoscopy, etc. in the 21st century. These endoscopic diagnostic techniques and clinical application methods are briefly introduced.

Cholangiocarcinoma is a malignant tumor originating from bile duct epithelial cells, which occurs in Thailand, China and South Korea. In China, the incidence of cholangiocarcinoma is>6/100,000, which is a common disease in China according to WHO standards. Cholangiocarcinoma can be divided into intrahepatic cholangiocarcinoma, hilar cholangiocarcinoma and distal cholangiocarcinoma according to anatomical site, among which hilar cholangiocarcinoma is the most common, accounting for about 50%. Due to its special location, hilar cholangiocarcinoma is difficult to diagnose and treat, which is a difficult point in clinical diagnosis and treatment.

liver cancer is a collective term for different types of primary liver cancer (PLC) in histology, including hepatocellular carcinoma, cholangiocarcinoma, hepatoblastoma, and angeioma. Among them, hepatocellular carcinoma accounts for more than 80% of the patients with liver cancer, and is the most common type of liver cancer^[1]。 The incidence of liver cancer is increasing year by year in the world. At present, it is the sixth most common malignant tumor, and the mortality rate ranks third, which poses a serious threat to people's health around the world. China has the highest incidence of liver cancer in the world, with annual new cases accounting for more than half of the global incidence^[2]。 At present, the best treatment for early stage liver cancer is liver resection, liver transplantation and radiofrequency ablation. However, due to its insidious onset, rapid progression and difficulty in early diagnosis, most patients have reached advanced stage or have metastasis at the time of diagnosis, so they can only undergo adjuvant comprehensive treatment^[1]。 Therefore, establishing a new typing system to accurately and specifically judge the prognosis of hepatocellular carcinoma and carrying out targeted drug intervention is the key link to carry out personalized prevention and treatment of hepatocellular carcinoma patients.

The incidence of esophageal cancer in China is at a high level in the world^[1]However, thyroid metastasis in esophageal cancer is clinically rare. In recent years, with the improvement of medical level and the increasing popularity of thyroid disease screening, the incidence of thyroid metastasis of esophageal cancer is gradually increasing. The clinical data of 9 patients with thyroid metastasis from esophageal cancer admitted to the First Affiliated Hospital of Zhengzhou University from January 2010 to December 2016 are summarized, and relevant literature at home and abroad are reviewed to explore their onset characteristics, diagnosis, differential diagnosis and treatment measures.

In recent years, with the vigorous development of endoscopic technology and the application of PPI, the mortality rate of acute nonvariceal upper gastrointestinal bleeding (ANVUGIB) has decreased significantly, but it still reaches 5% ~10%^[1]。 A meta-analysis of 93 clinical studies showed that the annual incidence of ANVUGIB was (19.4-57.0) per 100,000, the rebleeding rate 7 days after onset was 13.9%, and the mortality rate was 8.6%^[2]。 In 2010, an international consensus on the treatment of ANVUGIB suggested that early risk factor stratification of ANVUGIB patients and aggressive management of high-risk patients could reduce their rebleeding rates and mortality rates^[3]。 Therefore, it is particularly important to make a preliminary judgment on ANVUGIB patients, understand the severity of the disease, the development trend and choose a reasonable and effective treatment. This study retrospectively analyzed the clinical data of 292 patients with ANVUGIB in Xi'an Central Hospital, aiming to explore the risk factors affecting 30-d rebleeding and death.

Functional constipation is a "gut-brain" dysfunction disease^[1]In addition to clinical manifestations such as dry and hard stool, laborious defecation, difficulty in discharging, and incomplete defecation, patients are often complicated with emotional disorders such as anxiety and depression, especially patients with intractable constipation. fecal microbiota transplantation is an important means to interfere with intestinal flora imbalance, and has been used in the treatment of some diseases. fecal microbiota transplantation has also achieved good results in the treatment of colonic slow transit constipation in the intestinal microbiota treatment center of Jinling Hospital affiliated to Nanjing University School of Medicine^[2]。 In addition, it was found in clinical observations that some patients with intractable constipation had obvious depressive symptoms, which were relieved with the cure of constipation. This study observed the clinical efficacy of 18 patients with intractable constipation combined with depression treated with fecal bacteria transplantation, which is reported below.

pancreatic neuroendocrine tumor (PNET) is a rare disease involving the nervous system and endocrine system. With the improvement of diagnostic methods and the development of imaging technology, the incidence of PNET is increasing year by year, reaching 0.32/100,000 people^[1]。 Because PNET is rare and the manifestation of Cushing syndrome that occurs concomitantly in the early stage of the disease is not obvious, it is very difficult to diagnose PNET. The medical records of a patient with PNET admitted to Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine were retrospectively analyzed to explore the diagnosis and treatment of PNET.

Example 1A 54-year-old male was admitted to the hospital on 23 Mar 2017 due to upper abdominal discomfort for 2 months. There is intermittent discomfort in the upper abdomen, which can be slightly relieved after meals. Gastroscopy at the local hospital 4 days before admission revealed esophageal submucosal bulging lesions and chronic non-atrophic gastritis. Previous history of hypertension for 1 year, blood pressure up to 150/90 mmHg (1 mmHg =0.133 kPa), oral amlodipine (5 mg/dose, 1 dose/d), blood pressure control was acceptable. Physical examination: Vital signs were stable, and no obvious abnormalities were found in the heart, lungs and abdomen. Gastroscopy showed a mucosal bulge about 1.0 cm ×1.0 cm in size, slightly yellow, 38 cm away from the incisor (Figure 1)。 Endoscopic ultrasound showed that the second layer structure of the esophageal wall showed a moderately low echo occupation, the internal echo was not uniform, the boundary was clear, and the section size was 8.4 mm ×8.4 mm. Diagnosis: Esophageal mucosal muscle space-occupying ultrasound findings (because granulosa cell tumor cannot be excluded, endoscopic resection and pathological examination are recommended). There were no obvious abnormalities in blood routine, coagulation routine, blood biochemistry, immune routine and digestive tract tumor markers. endoscopic submucosal dissection (ESD) was performed under general anesthesia on 24 Mar 2017. During the operation, an argon knife was used to mark the surroundings of the protuberance lesions, and then 3 mL of glycerofructose added with methylene blue and epinephrine was injected under the basal mucosa to make the basal protuberance until the lesions were completely located at the top of the protuberance (Figure 2), use a needle-shaped electroknife to circumscribe along the outer edge of the mark, gradually peel it off under the mucosa, and use a snare to snare it (Figure 3), spraying the exposed blood vessels on the wound surface with an argon knife, and finally clamping the wound surface with a titanium clip (Figure 4)。 Immunohistochemical staining showed positive rates of S-100, CD68, neuron specific enolase (NSE), calretinin, α-inhibin and Ki-67<5%。 Biopsy pathological diagnosis: esophageal granulosa cell tumor (Figure 5)。 Postoperative fasting for 3 days showed no complications such as bleeding, perforation, fever and esophageal stenosis. After 5 d of observation, there was no discomfort after eating, and he was discharged.

Example 1A 87-year-old female was admitted to the hospital on 23-Jun-2015 due to melena for 1 d. The patient was treated with "gastrointestinal bleeding" in the Department of Gastroenterology of Huaibei People's Hospital for 3 times without inducement 1 day ago, with a dose of about 600 mL, accompanied by palpitation, paroxysmal cold sweating, no hematemesis, abdominal pain and fever. The patient had a history of diabetes mellitus for 10 years, long-term oral hypoglycemic drugs and enteric-coated aspirin, and no history of hepatitis. Physical examination at admission: body temperature 36.1℃, heart rate 88 beats/min, breathing 18 beats/min, blood pressure 105/65 mmHg (1 mmHg =0.133 kPa), clear, mild anemic appearance, no superficial lymph node swelling, normal heart and lung, soft abdomen, no abdominal tenderness, small liver and spleen, no palpable abdominal mass, and no special remaining. Routine blood white blood cell count was 8.43×10⁹/L, neutrophils accounted for 0.736, lymphocytes accounted for 0.144, and red blood cell count was 3.3×10¹²/L, hemoglobin was 102 g/L, and platelet count was 20.4×10⁹/L; Fecal occult blood test (+); There were no abnormalities in five indexes of liver function and hepatitis B; Abdominal ultrasonography showed no abnormalities in liver, gallbladder, spleen and pancreas. Preliminary diagnosis: upper gastrointestinal bleeding, etiology to be investigated. Treatments such as fluid rehydration, PPI and hemostatic agents were given. Because the family members refused to diagnose and treat gastroscopy considering the patient was old and frail, emergency gastroscopy was not performed on the same day. However, the patient still repeatedly relieved the tarmaceous melena for 4 times, with a volume of about 800 mL, and had an increase in heart rate and a decrease in blood pressure (80/50 mmHg). After re-examination, the hemoglobin dropped to 73 g/L. Considering that the patient had active bleeding, he was treated with active rehydration, blood transfusion and other volume expansion treatments. After the circulation was relatively stable, the family members were informed of the necessity of gastroscopy diagnosis and treatment again, and gastroscopy was agreed. On the second day, emergency gastroscopy diagnosis and treatment were performed. Under the microscope, the esophageal mucosa was smooth, no varicose veins, and a small amount of blood accumulated in the gastric cavity; The blood stains attached to the stomach wall were repeatedly washed, and the gastric mucosa was smooth, without erosion and ulcer, and no bleeding lesions were observed. When entering the duodenum, there was a large amount of blood accumulation in the bulb cavity and the descending part of the duodenum. After irrigation, careful exploration showed that the bulb and duodenal mucosa were smooth. A wide-mouthed diverticulum was seen 3 cm above the main duodenal papilla, and there was blood accumulation in the diverticulum. After irrigation, a mucosal damage was found at the bottom of the diverticulum, with a diameter of about 3 mm, and the surface blood vessels were exposed. It was clipped with 4 hemostatic clips (Figure 1) and observed for 10 min, no bleeding was observed. Final diagnosis: Dieulafoy's disease in the diverticulum of the descending duodenum. The basic condition of the patient was good after operation, there was no further bleeding, and he was cured and discharged.

Several studies have confirmed that the diagnostic accuracy of magnetic-controlled capsule gastroscope for gastric diseases is highly consistent with that of traditional electronic gastroscope, and it has the advantages of comfort, safety, no need for anesthesia, and no risk of cross-infection. At present, magnetic-controlled capsule gastroscope has been widely used in hundreds of medical institutions at home and abroad, with 100,000 clinical applications. It is a useful supplement to traditional electronic gastroscope and an important tool for primary screening and examination of gastric diseases. In order to ensure the medical quality of the magnetic-controlled capsule gastroscope system, the National Digestive Endoscopy Quality Control Center organized a number of experts through many rounds of meetings and discussions, combined with the actual operation of the magnetic-controlled capsule gastroscope examination room in China, and the clinical research of magnetic-controlled capsule gastroscope, and referring to the expert consensus of safe operation of the digestive endoscopy center in China and the expert consensus of clinical application of magnetic-controlled capsule gastroscope, this medical quality control technical specification is specially formulated.

Fusobacterium nucleatum (Fusobacterium nucleatum，F.nucleatum) is a spore-free obligate anaerobic bacillus widely found in humans and many animals^[1]。 PastF.nucleatumIt has always been regarded as one of the normal bacteria in human body, especially in oropharynx. In recent years, it has been isolated from clinical specimens and found that its distribution between normal tissues and diseased tissues is different. It has been confirmed as a conditional pathogen and its detection significance has been paid more and more attention.

colorectal cancer is one of the leading causes of tumor-related death worldwide. The latest research shows that colorectal cancer ranks among the top 5 in cancer incidence and mortality in China^[1]。 The most common precancerous lesions of colorectal cancer are traditional adenomas, and about 30% are serrated polyps^[2]。 Longacre and Fenoglio-Preiser^[3]For the first time, a new type of adenoma with both serrated structure of hyperplastic polyp (HP) and atypical epithelial characteristics of traditional adenomas is named serrated adenoma (SA). The malignant potential of colorectal serrated lesions has been neglected in the past, but the proposed carcinogenic mechanism of serrated pathway based on molecular biology has improved people's further understanding of the pathogenesis of colorectal cancer. In 2000, the WHO classification of digestive system tumors officially listed SA as a separate colorectal tumor type. Its characteristic morphology is a serrated structure similar to HP and a glandular epithelium with dysplasia. SA is divided into three subtypes: HP, sessile serrated adenoma/polyps (SSA/P) and traditional serrated adenoma (TSA), but its diagnostic criteria and malignant potential are still controversial. Among them, unlike HP, TSA and SSA/P are considered to be the main pre-stage lesions of the serrated pathway.