2 English reference intestinal polyps
3 diseases alias intestinal polyposis, intestinal polyposis.
4 disease code ICD:K5 1.4
5 Classification of diseases Gastroenterology
6 disease overview colorectal polyps (polyps? Yes? Intestines? Tao) is the general term for all vegetations protruding into the intestinal cavity, including neoplastic and non-neoplastic ones. Most colorectal adenomas have occult onset without any clinical symptoms. A few of them show changes in stool habits, blood and mucus in stool, thin stool, increased frequency, abdominal discomfort to varying degrees, occasional abdominal pain, emaciation, anemia and other systemic symptoms, and a few have tumors coming out of stool. Cases with family history are often helpful to the diagnosis of polyps. Anyone with unexplained bloody stool or digestive tract symptoms, especially middle-aged and elderly men over 40 years old, should pay attention to further examination to improve the detection rate and diagnosis rate of colorectal polyps.
7 disease description colorectal polyps (polyps? Yes? Intestines? Tao) is the general term for all vegetations protruding into the intestinal cavity, including neoplastic and non-neoplastic ones. Tumor * * * meat (Tumorous? Polyp) is a true tumor with epithelial hyperplasia of large intestine, and its single tumor is collectively called adenoma, which can be divided into three types according to its histological characteristics and biological behavior: glandular tubular, villous and mixed; They are closely related to cancer, with varying degrees of malignant transformation rate, and are a precancerous lesion or state. Non-neoplastic flesh, less cancer. Because these two kinds of polyps are difficult to distinguish in clinic, the so-called colorectal polyps in clinic cannot explain the pathological nature of polyps. Usually, what clinicians call polyps are mostly non-neoplastic meat, so polyps are often used as a preliminary diagnosis, and further classification is made after pathological examination, which has more important clinical significance for the diagnosis of adenoma.
8 Symptoms and signs Most colorectal adenomas have hidden onset and no clinical symptoms. A few of them show changes in stool habits, blood and mucus in stool, thin stool, increased frequency, abdominal discomfort to varying degrees, occasional abdominal pain, emaciation, anemia and other systemic symptoms, and a few have tumors coming out of stool. Cases with family history are often helpful to the diagnosis of polyps. Some typical parenteral symptoms often suggest the possibility of polyposis, and some patients often go to see a doctor because of parenteral symptoms, which must not be ignored. Because the clinical symptoms of this disease are few, it is easy to ignore or miss the diagnosis. Therefore, the diagnosis of colonic polyps should first improve the understanding of this disease. Anyone with unexplained hematochezia or digestive tract symptoms, especially middle-aged and elderly men over 40 years old, should pay attention to further examination to improve the detection rate and diagnosis rate of colorectal polyps.
There are many ways to classify colorectal polyps according to the number of polyps, but at present, colorectal polyps are generally classified into tumor, hamartoma, inflammation and hyperplasia according to Morson's histological classification (table 1) at home and abroad.
The biggest advantage of this classification is that colorectal polyps are collectively referred to as adenomas, and other non-neoplastic meats are collectively referred to as polyps. Evolved into adenoma. This classification can clearly distinguish the pathological properties of colorectal polyps and has great guiding significance for treatment.
The histogenesis of 10 pathophysiological adenoma is still unclear. The preliminary study shows that the deep crypt cells develop gradually with the migration to the surface and atypical proliferation. Sulfate mucus is mainly expressed in the deep epithelium of normal crypt, while sulfate mucus is more than sialic acid mucus in adenoma epithelium. Recent studies show that Ley blood group antigen is diffusely stained in many adenomas, but it is only found in the deep recess of normal mucosa. The consistency of histochemical reaction between these adenoma epithelium and deep crypt epithelium strongly supports the possibility that adenoma originated from deep crypt. Another hypothesis of the origin of adenoma is eosinophilic epithelium, which is often located near the adenoma epithelium, and there is migration between them. On the basis of the theory of colorectal adenoma → colorectal cancer, there is a sequential phenomenon of normal colorectal mucosa → tubular adenoma → tubular adenoma → tubular adenoma → colorectal cancer. It is believed that adenomas are mostly tubular adenomas at first, then gradually transformed into tubular vocal cord adenomas and vocal cord adenomas, and finally evolved into colorectal cancer. At the same time, tubular adenoma and tubular villous adenoma will also become cancerous. No matter where the adenoma occurs in the recess, the proliferation of adenoma tissue is mainly to form a lump protruding to the surface of the lumen. Although all adenomas initially grow in the form of broad base, with the enlargement of adenomas, some adenomas become pedicled or nearly sessile. In descending colon and sigmoid colon, pedicled polyps are easier to form here than in other parts of the intestine due to strong intestinal peristalsis and fecal formation.
1. colorectal adenoma? The histological features of adenoma are not only the histological basis of adenoma classification, but also the basis of adenoma diagnosis. Adenomas are divided into tubular adenoma, villous adenoma and mixed adenoma (tubular villous adenoma). Villous components are often seen in histological sections of adenomas, which are many slender branches protruding from the pathological base and rich mucus secretion can be seen. The cable core is composed of loose fibrous connective tissue, and its surface is covered with one or more layers of columnar epithelial cells. The number of villi is positively correlated with the malignant degree of adenoma, so a correct evaluation of the number of villi contained in adenoma is helpful to judge the malignant potential of adenoma. It should be understood that the distribution of villi components in different parts of the same adenoma is different, and the pathological diagnosis of tissues taken by biopsy in different parts can be different. Histologically, in the early stage of tubular adenoma, only high columnar cells were densely arranged in the crypt, with deep nuclear staining and goblet cells decreased and disappeared. The progress of the lesion showed obvious hyperplasia, extension, branching and expansion of glandular ducts, different sizes of glandular cavities and proliferation of epithelial cells. Protruding into the cavity tends to form * * * *; The nucleus is deeply stained, with a small amount of mitosis, but all of them are located in the basement, and there are a small amount of connective tissue, small vessels and inflammatory cells infiltrating in the stroma. Different from tubular adenoma, villous adenoma usually occurs on the epithelial surface of the large intestine and grows into the intestinal cavity, forming a * * * *-shaped bump. Histologically, it is a typical fine villous structure. Villi are often directly connected with the mucosal surface, and there are single or multiple columnar epithelial cells on the surface. Cells vary in size and are arranged regularly. Nuclear staining is located in the basement, and mitotic images are common. Chorionic nucleus of villi is composed of fibrous connective tissue with unequal infiltration of small blood vessels and inflammatory cells. Mixed adenoma is histologically based on tubular adenoma and mixed with villous adenoma.
2. Colorectal adenoma canceration? The canceration of adenoma is characterized by nuclear atypia, loss of polarity, increased ratio of nucleoplasm and multiple mitotic images. According to the depth of invasion, it can be divided into carcinoma in situ and invasive carcinoma, with the muscularis mucosa as the boundary. The reason why carcinoma in situ does not metastasize is that there are no lymphatic vessels in the lamina propria of intestinal mucosa. Therefore, the canceration of adenoma is often aimed at invasive cancer in clinic. The vast majority of colorectal cancer comes from colorectal adenoma canceration, and the main factors affecting adenoma canceration are atypical hyperplasia, adenoma enlargement and villous component hyperplasia, which can aggravate atypical proliferation of cells. Adenomas with a diameter less than 1cm rarely become cancerous. The canceration rate of tubular adenoma is low, while the canceration rate of villous adenoma is about five times that of tubular adenoma.
3. Familial multiple adenomatosis? The disease is an autosomal dominant genetic disease. Endoscopy showed a large number of small adenomas, most of which were only a few millimeters in size, and a few were larger than 1cm. The shape is sessile semi-ring, nodular uplift, smooth or lobulated surface, soft reddish color, pedicled or sessile, and carpet-like structure in dense areas. Histologically, it is basically the same as adenoma, with rare hyperplasia, but high incidence of canceration. Canceration will eventually occur within 5 ~ 20 years. The average age of canceration is 39 years old, and multicenter occurrence is more common.
4. Turcotte syndrome? This disease is characterized by multiple adenomas in the large intestine and malignant tumors in the central nervous system. It belongs to autosomal recessive inheritance and is different from familial adenomatosis. Adenomas are also distributed throughout the large intestine, but the number is small and scattered. /kloc-rarely exceeds 100 pieces within 0/0 years old, and 100 pieces over 0/0 years old. Canceration occurs at an early age, generally under the age of 20, which is more common in women.
5. Gardner syndrome? Four kinds of pathological changes:
(1) Multiple adenoma of large intestine.
(2) Osteomas (mainly occurring in jaws, skulls and long bones).
(3) desmoid tumor (mostly in postoperative mesentery).
(4) Cutaneous tumor-like lesions (including seborrheic cysts and epidermoid cysts, mostly located in the head, back, face and limbs, with some tooth deformities).
Some said that all the above lesions were completed. For example, two of the last three lesions are incomplete, and only 1 lesion is simple. It is generally believed that its heredity, onset age, number, type, distribution and canceration probability are the same as those of ordinary familial adenomas. Clinically, compared with familial adenomas, colorectal adenomas have a later onset age and can appear after symptoms outside the digestive tract, with fewer adenomas.
6.PeutzJephers syndrome? Also known as hamartomatosis, it belongs to autosomal dominant inheritance, but only half of it has a family history in clinic. It is characterized by: multiple meat in gastrointestinal tract; Inherited; Melanin spots appear on the skin and mucous membrane in specific parts, and black spots mainly appear on the skin and buccal mucosa around the lips, with clear edges and a diameter of about 1 ~ 2mm. Histologically, the number of melanocytes in dermal matrix increased, resulting in melanosis. There are more than 100 polyps, most of which are in small intestine (64% ~ 96%) and large intestine (30% ~ 50%). This disease may also become cancer.
1 1 diagnostic examination 12 diagnosis 1. Clinical manifestations.
2.x？ X ray examination
3. Endoscopy.
There are three ways to detect polyps. The most common is that patients come to see a doctor because of intestinal dysfunction (such as irritable bowel syndrome). ) or unexpected discovery of rectal bleeding; The second type was found in the asymptomatic census; The third is that the polyp is large, and the patient comes to see a doctor and finds out the polyp because of the symptoms of bloody stool or polyp itself. Because most polyps have no clinical signs, it is very limited to find polyps by the third way.
13 laboratory fecal occult blood test: its diagnostic significance is limited and there are many false negatives. Positive people can provide clues for further examination.
14 Other supplementary exams 1. X-ray? X-ray barium can sensitively find colorectal polyps through the filling defect of barium, but it is often unable to correctly classify and characterize the lesions.
2. Endoscopy? Endoscopy can not only observe the microscopic lesions of colorectal mucosa under direct vision, but also determine the nature of lesions through tissue biopsy and cytological brush examination, so it is the most important means to find and diagnose colorectal polyps. All polyps found by endoscopy should be biopsied to understand the nature, type and canceration of polyps. Small or pedicled polyps can be taken out with biopsy forceps or snares and sent for examination, while large or huge polyps with wide base can only be biopsied with forceps. Because of the high incidence of the disease in the population, it is often found occasionally in the general survey of colon cancer or in the further examination of patients with gastrointestinal discomfort. If colonoscopy finds polyps with a diameter less than 1cm, biopsy is usually needed, and then further treatment is carried out according to the pathological results; If it is a polyp with a diameter greater than 1cm, the polyp can be taken out directly under colonoscopy without biopsy. If polyps are found under sigmoidoscopy and confirmed as adenomas by biopsy, further colonoscopy is needed to exclude other adenomas or redundant lesions that may exist in the proximal colon.
Because the content of villi in different parts of the same adenoma and the degree of atypical hyperplasia are different, the lesions in the biopsy site by forceps can not fully represent the whole picture, and it is not certain that the biopsy site is not cancerous. Therefore, the atypical hyperplasia and non-cancerous degree of adenoma often need to remove the whole tumor, and the diagnosis can be made only after careful section examination. The pathological results of clamp biopsy can be referenced, but it is not the final conclusion. Clinically, preoperative forceps biopsy results are different from postoperative pathological diagnosis, which is quite common in villous adenoma.
The differential diagnosis of 15 adenoma is that the epithelial tissue of the large intestine protrudes into the intestinal cavity, and its appearance is slightly red, so it can be distinguished from gray hyperplastic meat, but even the diagnosis by experienced endoscopists is less than 70%. Misdiagnosis is easy to occur for adenomas with a diameter below 0.5cm or hyperplastic meat with a diameter above 0.5 cm.
1. Tubular adenomas are mostly tubular adenomas, mainly occurring in rectum and sigmoid colon, with pedicled adenomas accounting for 85%. The size varies from a few millimeters to 10cm, and adenomas with a diameter of 1 ~ 2 cm are more common. Most adenomas are spherical or hemispherical, with smooth surface, shallow cracks, obvious congestion and redness, and some have bleeding spots, forming a tiger-like structure. When there is secondary infection, mucus purulent secretion is attached to the surface. 5% ~ 10% of tubular adenomas are adjacent to the mucosa around the pedicle, and even white spots may appear in the intestinal mucosa opposite to the adenoma. The leukoplakia is punctate and distributed in clusters, and the histological changes are mainly inflammatory changes.
2. villous adenoma is more common in adults over 50 years old and less common. It is more common in the left colon, of which rectum accounts for about 82%, sigmoid colon accounts for about 13%, and right colon is rare. Brittle texture, often accompanied by erosion and bleeding, generally larger than 2cm in diameter, larger than tubular adenoma, and gradually increasing with age; The surface is not smooth, there are countless fine villous protrusions, often accompanied by a lot of mucus; Most of them are sessile and pedicled, accounting for only 65,438+07%, with irregular shape. Pedicels are flower beds or vegetables, and pedicels are like a bunch of grapes.
3. Mixed adenoma is similar to tubular adenoma, with pedicle and pedicle, which is characterized by unsmooth surface, deep fissure, lobulated shape and many villous processes.
4. The main symptoms of familial multiple adenomatosis are bloody stool and mucus. Cancer patients often have intestinal obstruction, and there are asymptomatic patients. Familial adenomatosis is characterized by multiple adenomas in the large intestine, the number of which exceeds 100. Adenomas are distributed in the left colon, especially in the sigmoid colon and rectum. X-ray shows a circular filling defect widely distributed in the whole large intestine, with a diameter of 0.3 ~ 0.5 cm and a smooth contour. In the area with dense polyps, the double contrast examination of air and barium is very similar to the corn-like arrangement, but the traditional barium is easily submerged by barium and missed diagnosis.
16 treatment plan 1. Non-surgical treatment? The treatment principle of colorectal polyps is to remove them as soon as they are found. The choice of treatment depends on their location, pedicle, size and malignant potential. Non-surgical treatment is mainly endoscopic high-frequency electrocoagulation polypectomy, or laser or microwave resection. Before operation, the intestine was clean and prepared, and the coagulation mechanism was unobstructed. After operation, remove the intestine, eat some juice or have an empty stomach 1 ~ 3? Days, limit activity, intravenous hemostasis (such as sulfamethazine 3.0g/d), anti-inflammation (antibiotics against gram-positive bacteria), and protect intestinal mucosa (octahedral montmorillonite, etc.). ), closely observe the color of stool, bowel sounds, etc. And pay close attention to the occurrence of bleeding and perforation.
(1) High-frequency electrocoagulation: According to the shape, size, quantity and pedicel of polyps, the following methods can be adopted.
① High-frequency electrocoagulation cautery: mainly used for multiple small hemisphere polyps.
② High-frequency electrocoagulation snare excision: mainly used for pedicled polyps.
③ "Close contact" resection method: it is mainly used for large polyps with long pedicles, and electrocoagulation resection method is used for large polyps that are difficult to hang into intestinal cavity.
④ High-frequency electrocoagulation biopsy forceps method: it is rarely used at present.
(2) Biopsy forceps division: it is mainly used for single or a few small spherical polyps, which is simple and feasible, and biopsy is also desirable.
(3) Staged and batch resection: it is mainly used for patients with 10 ~ 20 polyps who cannot be resected at one time.
(4) Laser gasification method and microwave diathermy method: suitable for those who do not need to preserve histological specimens.
2. Surgical treatment? Patients with polyposis can be treated by combining endoscopy with surgery, which can not only achieve the therapeutic purpose, but also maintain the normal function of the large intestine. Surgical indications are often: 10 or above, which is large and confined to a certain intestinal segment; Larger polyps block most of the intestinal cavity, and the pedicle shows an unclear or wide adenoma with a basal diameter of > 2 cm. The recurrence rate of colorectal adenoma after resection is high, and there is the possibility of multiple adenomas. Careful clinical follow-up plan should be made according to the histological type of patients, so as to find the lesions early and treat them in time. Malignant colorectal polyps refer to adenomas containing invasive cancer cells, some of which pass through the muscularis mucosa and enter the submucosa. Compared with adenomas with severe atypical hyperplasia, cancer cells in malignant adenomas are not confined to mucous membranes, so there is a possibility of metastasis. The indication of surgical treatment should be determined according to whether there are residual cancer cells or lymph node metastasis in the base of polypectomy. When a polyp is suspected to be malignant during colonoscopy, the endoscopist should first evaluate whether it can be removed under endoscope. Pedicled or small sessile polyps can be completely removed, and large sessile polyps should be biopsied first. After polypectomy, all tissues should be sent for pathological examination (that is, the whole tumor examination), and the location of polyps should be described in detail, because if polyps are found to be malignant, they must be treated surgically. Indian ink can also be injected into the intestinal wall of the polypectomy site, leaving a permanent positioning mark for the possible surgical site in the future.
3. Regular follow-up? Because colorectal polyps, especially adenomas, have been recognized as precancerous lesions or diseases by scholars, regular follow-up of patients with colorectal polyps has risen to the height of prevention and treatment of early colorectal cancer. Regular follow-up of colorectal polyps, especially adenomatous polyps, is an important link to prevent polyps from becoming malignant. The re-detection rate of polyps is relatively high, which is reported as 13%-86% abroad. Except for some recurrent polyps, the residual polyps grow again, and some newly detected polyps are new polyps and missing polyps in the large intestine. In order to maintain the absence of intestinal polyps and prevent the occurrence of colorectal cancer, it is necessary to make an economical and effective follow-up plan.
The main complications of 17 are emaciation and anemia.
18 prognosis and prevention 19 prognosis colorectal adenoma group discussed the proposed scheme in detail at the third international colorectal cancer conference held in Boston. They pointed out that after adenoma resection, the risk of recurrence of new adenoma and local adenoma is different and should be treated differently.
(1) low-risk group: single tubular adenoma with pedicle (or broad base) but less than 2 cm, accompanied by mild to moderate atypical hyperplasia. In the low-risk group, the adenoma was reexamined 1 year after resection. If it is negative, you can check 1 time every 3 years, ***2 times, and then check 1 time every 5 years. However, during the follow-up period, fecal occult blood test should be done every year. Once the polyp is found in the reexamination, it will be removed by endoscope.
(2) High-risk group: one of the following cases is high-risk: multiple adenomas, villous or mixed adenomas with a diameter greater than 2 cm, adenomas with severe atypical hyperplasia or carcinoma in situ, and adenomas with invasive canceration. The follow-up plan of the high-risk group is to remove the adenoma for 3-6 months, and then do endoscopy every 6-9 months. If it is negative again, it can be checked every 1 year. If it is still negative, it should be checked every 3 years, during which it is necessary to check the fecal occult blood every year.
20 Prevention In recent years, it has been reported that long-term oral administration of non-steroidal anti-inflammatory drugs such as sulindac can prevent the recurrence of polyps, but attention should be paid to other side effects of drugs. At the same time, the effect of this preventive treatment remains to be seen in a large number of cases.
2 1 Epidemiology Polyps are mostly asymptomatic, and their incidence varies with subjects, age, gender, geographical environment and examination methods. The incidence of literature reports varies greatly, ranging from 10% to 66%. Except for familial and juvenile meat, which often appears in adolescence, it is generally found after middle age, and with the increase of age, the elderly over 60 account for about 75%. Male is higher than female, about 2∶ 1.
In particular, there is no special prevention method for this disease.
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Tremor paralysis, hemifacial spasm, oral cavity? Rhinitis, nasal congestion, nosebleed, nasal polyps, corpse syncope, etc. Alias: He30 ("1000 emergency"), long frequency ( ...
Long-term paralysis, facial spasm, mouth? Rhinitis, nasal congestion, nosebleed, nasal polyps, corpse syncope, etc. Alias: He30 ("1000 emergency"), long frequency ( ...
Mouth paralysis, hemifacial spasm, mouth? Rhinitis, nasal congestion, nosebleed, nasal polyps, corpse syncope, etc. Alias: He30 ("1000 emergency"), long frequency ( ...
Hmm. How interesting