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1、,Good afternoon!,Last time, we have studied the examination methods , the normal representations and the essential lesions in digestive system, now we begin to learn the common diseases.,食管静脉曲张 esophageal varices,Esophageal varices result from dilatation of submucosal veins in the esophagus acting a
2、s collateral venous drainage in the presence of obstruction elsewhere. Usually this is caused by cirrhosis of the liver so that portal blood flow is rerouted via the esophagus to the superior vena cava.,pathomechanism 病理机制Because of portal hypertension, the excess blood from the left gastric vein an
3、d the short gastric vein flow into the submucosal veins in the distal region of esophagus and the perioesophageal venous plexus. Azygos vein and IVC dilatation result in the esophageal varices. 门V系统高压，大量静脉血液自胃冠状V和胃短V食管远段粘膜下V和食管周围V丛奇静脉上腔V，致胃底V和食管下段V曲张(上行性V曲张)。,esophageal varices 食管静脉曲张,clinical sympt
4、oms 临床症状The main symptoms is haematemesis. The patient may have cirrhosis in the history. 主要为呕血(有肝硬化等门V高压史),门静脉高压侧支循环的建立途径,1）胃底食管下端交通支门静脉经胃冠状静脉、胃短静脉、胃后静脉，门静脉高压时，门静脉血液科经食管静脉和奇静脉流入上腔静脉。 2）直肠下端、肛管交通支门静脉经肠系膜下静脉、直肠上静脉与上述静脉汇合流入下腔静脉，门静脉高压时可形成顽固性痔疮。,3）前腹壁交通支在脐周脐旁静脉与腹上深静脉、腹下深静脉相同，分别流入上、下腔静脉、附脐静脉与腹壁上下静脉以及胸壁静脉
5、相交通，门静脉高压时，脐周围腹壁浅静脉曲张，形成“海蛇头”。 4）腹膜后交通之 脾静脉、肠系膜上、下静脉分别与下腔静脉分支相互交通吻合。包括腰静脉、低位的肋间静脉、膈下静脉及睾丸（卵巢）静脉相吻合，形成Retzius静脉。腰静脉向上汇合成奇静脉和半奇静脉。,肝静脉及下腔静脉回流示意图 the hepatic veins and inferior vena cava circum,门脉高压侧支循环示意图,下腔静脉与腰静脉侧支循环示意图,Esophageal varices are a common - and dangerous complication of alcoholic cirrhos
6、is , and the bleeding from the varices is a medical emergency.,Esophageal VaricesEndoscope veiw,食管静脉曲张食管吞钡表现： 轻度：病变局限于下段，粘膜皱襞稍增宽、迂曲，管壁锯齿状，蠕动正常 中度：范围可延至中段，粘膜呈蚯蚓状、串珠状、管腔收缩欠佳，排空延迟 重度：范围更广，甚至全食管，食管明显扩张，不易收缩，腔内可见环状、囊状充盈缺损，但管壁柔软 胃底静脉曲张胃钡餐表现：空泡状葡萄样充盈缺损,gastric fundus varices 胃底静脉曲张 空泡状葡萄样充盈缺损, MR表现门脉造影加MIP
7、重建可显示曲张的食管静脉网，效果近似于血管造影。食管周围可见管状或圆点状流空低信号影 血管造影采用经肠系膜上动脉插管的间接门静脉造影 CT表现平扫食管壁增厚，食管周围可见管状或圆点状软组织密度影。增强扫描和静脉密度一致，显示更清晰。,Azygos vein,Hemiazygos vein,Oesophageal varices. Barium swallow. Revealing longitudinal serpiginous filling defects in middle and distal portion of the oesophagus.,CT at mid-chest lev
8、el demonstrates multiple tubular and rounded contrast enhanced structures surrounding the oesophagus and representing perioesophageal varices (large arrows). Enhancement of the thickened oesophageal wall (small arrow) is due to enlarged submucosal contrast enhanced varices.,Oesophageal varices,贲门失驰缓
9、症 achalasia,Histological examination of esophagus usually demonstrates degeneration of the vagus nerve plexus in the region of the gastro-esophageal junction. The end result is a failure of relaxation of the gastro-esophageal junction, but in most cases probably the whole of the esophagus is abnorma
10、l.,Clinical manifestations 临床表现女性多于常见，下咽不畅，胸骨后阻塞感，病程长，周期性呕吐，有时可用热水、药物缓解。,影像学表现 轻度：食管轻度扩张，食管下端光滑，呈纺锤状、鸟嘴状，有锯齿样收缩 中度：食管中度扩张，46cm，典型鸟嘴状 重度：食管高度扩张，6cm，正位可见纵隔增宽，常有呼吸道并发症。,食管癌 (carcinoma of esophagus),Esophageal carcinoma is one of the most common malignant tumors, the vast majority are males. About 80%-9
11、0% of these tumors are squmous cell carcinomas, and the remaining 10%-20% are adenocarcinomas. The lesions are often located in the middle third of esophagus. The main symptoms is progressive dysphagia, accompanying retrosternal burning-like or thorn-like pain.,常见的恶性肿瘤，男多于女，40岁以上 细胞类型：多为鳞状上皮癌，少数为腺癌多
12、见于(食管下端)，以食管中段为好发部位。 临床症状：以进行性吞咽困难为主要症状，伴有 胸骨后疼痛，灼疼、刺疼。,Definition: Eearly esophageal cancer is defined histologically as cancer limited to the mucosa or submucosa without lymph node metastases. The other term is that small esophageal cancer used to describe tumors less than 3.5 cm in size, regardle
13、ss of the depth of invasion or the presence or absence of lymph node metastases. 定义：癌仅浸润食管粘膜及粘膜下层，无淋巴结转移者. 另一概念是小食管癌，指病变不大于3.5 cm ，而不管病变侵犯的深度和有无淋巴结转移。 大体病理形态：平坦型、轻微凹陷型、轻微隆起型,Early esophageal cancer 早期食管癌,The mucosa changes ： The mucosa is thickening, discontinue, winding in mucosal relief . It usual
14、ly is manifested on double contrast studies by coarse, multiple small plaque or irregular reticular in esophageal mucosa. Slightly papillose or small nodulose filling defect (protrude type). irregular and small light barium fleck(slightly obtuse),X-manifestaions ：,The outline changes ：The esophageal
15、 wall may be irregular, slightly stiff or lightly spasm.,X线表现： 粘膜改变： 增粗、中断、迂曲不均(粘膜相) 粘膜面粗糙、呈细颗粒状或不规则网格状(双重对比相) 小息肉状或小结节状充盈缺损(隆起型) 不规则小浅钡斑(轻凹型) 轮廓改变：局部管壁轻微不规则、略硬、轻度痉挛,Advanced esophageal carcinoma 中晚期食管癌 X线表现： 粘膜改变：粘膜皱襞消失、紊乱、中断、破坏 癌肿侵犯肌层病变区管壁僵硬、扩张受限、蠕动减弱甚至消失。 管腔轮廓不规则，伴腔内充盈缺损、狭窄 钡剂通过受限，病变区上方食道扩张，有逆蠕动
16、如肿瘤向腔外生长明显可于纵隔内见肿块影,大体病理形态： 髓质型：肿瘤向腔内外生长，故腔内可见充盈缺损，纵隔内可见软组织肿块 蕈伞型：腔内不规则充盈缺损、管腔偏心狭窄 溃疡型：长行扁平状钡斑，底部不规则，周围有结节状充盈缺损 缩窄型：管壁内浸润收缩狭窄，呈环形或漏斗状,食管癌并发症： 食管癌穿孔和瘘道形成 食管癌淋巴结转移 鉴别诊断： 食管静脉曲张 贲门失驰缓症 食管裂孔疝伴食管炎引起的食管狭窄,left figure：esophago- mediastinal fistula 食管纵隔瘘 right figure：esophago-tracheal fistula 食管气管瘘,食管癌术后吻合口狭窄 Postoperation: anastomosis stricture,anastomosis stenosis: implantation a esophageal stent,CT：管壁增厚，管腔肿块，食管周围脂肪层模糊消失，周围器官受累，淋巴结和血源性转移。 MRI可多方位成像 增强扫描有强化,
