共聚焦激光显微内镜对胃黏膜肠上皮化生的分级诊断

Diagnostic value of confocai laser endomicroscopy in predicting the grading of gastric intestinal metaplasia

目的应用共聚焦激光显微内镜对胃黏膜肠上皮化生（GIM）的严重程度进行即时诊断，探讨该内镜对GIM分级诊断的价值。方法采用Pentax EC3870K共聚焦激光显微内镜对已知GIM患者进行检查，即时判断有无GIM，根据肠化面积及杯状细胞数量，借鉴新悉尼标准，判断严重程度（分为轻、中、重度），以病理诊断为金标准。对轻、中、重度GIM进行分型诊断，判断是否合并异型增生，检测Ki67表达情况。结果共扫描58例患者的GIM阳性部位151个，有92、34和25个部位分别被诊断为轻、中、重度GIM。经病理证实有146个部位存在GIM，总诊断阳性率96．7％。其中轻、中、重度GIM部位分别有82、36、28个。共聚焦激光显微内镜对轻、中、重度GIM诊断的敏感性和特异性分别是90．2％和73．9％、69．4％和92．2％、71.4％和95．9％，与病理诊断一致性的K值分别是0．65、0．63、0．70。GIM越严重，不完全型GIM的比例、伴异型增生的比例、Ki67的表达强度越高。结论共聚焦激光显微内镜可在胃镜检查时对GIM的严重程度作出即时、准确的诊断。分级诊断有临床指导意义。

Objective To evaluate the efficacy of confocal laser endomicroscopy （CLE） for the assessment of the grading of gastric intestinal metaplasia （GIM） in vivo. Methods Patients with known GIM underwent CLE （Pentax EC-3870K）. The presence of GIM was indentified immediately by the endoscopist during the procedure. The updated Sydney Classifycation System as reference, GIM was subdivided as mild, moderate and severe according to the area of intestinal metaplasia glands and the number of goblet cells. The histological evaluation remained the gold standard for the final diagnosis of GIM. The presence of the dysplasia and the expression of the Ki67 were examined. Results A total of 151 GIM positive areas were found in 58 patients with mild in 92, moderate in 34, and severe in 25 by CLE. One hundred and forty-six GIM areas were examined histopathologically with positive rate of 96.7 % （mild in 82, moderate in 36 and severe in 28）. The sensitivity and specificity of CLE were 90.2% and 73.9% in diagnosis of mild GIM, 69.4% and 92.2% in moderate GIM, 71.4% and 95.9 % in severe GIM. The kappa coefficient of CLE criteria and the histopathological grading for mild, moderate and severe GIM were 0.65, 0.63 and 0.70, respectively. The more severe the GIM, the higher the ratio of incomplete GIM, the ratio of dysplasia and the stronger expression of Ki67. Conclusions CLE may offer an instant and reliable diagnosis for GIM with high accuracy. It is helpful in grading of GIM.