Biopsy is a kind of method which can be used by endoscopists to take materials and send them to the pathology department, fix them, dehydrate them, bury them, slice them, dye them, and finally judge the nature of the lesions under the microscope.
At present, six biopsy techniques are routinely carried out in China:
1. Cell brush test
2. Tissue biopsy forceps 3. Tunnel biopsy technology 4. Mass biopsy technology emr5. Whole tumor biopsy technology esd6. Ultrasound guided FNA
I. cell brush test
Advantages: extensive scanning, a large number of smears, simple and easy
Use value: mycotic esophagitis bile duct brush examination can quickly detect other lesions in suspected gastrointestinal cancer with malignant stenosis
Tissue biopsy forceps
1. HP test
2. Tissue biopsy 3. Foreign body extraction (later topic discussion and learning) 4. Measurement size / judgment o-is or IIA (later topic discussion and learning) 5. Adjustment of opening position of papilla in diverticulum (later topic discussion and learning)
1. Rapid urease test of biopsy tissue HP invasive detection:
Principle: HP can produce highly active urease advantages: fast, specificity and sensitivity are greater than 90% disadvantages: HP in the stomach is mostly focal distribution, the material has one-sided, affected by the number of bacteria, prone to false negative. There is no difference in the infection rate of HP in antrum, antrum and body of stomach. It is better to take samples from multiple points under gastroscope and control the observation time within 30 minutes in rut experiment.
2. Tissue biopsy:
Four basic principles of targeted biopsy with biopsy forceps
a. For selective biopsy, the first specimen should be as accurate as possible to avoid the bleeding of biopsy affecting the follow-up operation; B. the specimen should be large enough and deep enough to reach the muscularis mucosa; C. for different lesions, different biopsy sites should be selected: the protruding lesions should be biopsied at the top (congestion, erosion, etc.) and the base (erosion, uneven, color change, etc.); flat Biopsy should be performed around or in the center of the lesion and at the break of the mucosal plica. In order to avoid necrotic tissue, biopsy should be carried out at the edge of mucosal eminence; D. the order of biopsy should be determined according to the position of biopsy point
(1) Three steps of endoscopic diagnosis before biopsy: judge whether there is pathological change, judge whether the pathological change is benign or malignant, and judge whether the pathological change needs endoscopic treatment or surgical treatment
(2) the correct method of targeted biopsy: it can not accurately bite the position, resulting in the increase of false negative rate of cancer, or it is to take the superficial lesions at the position of 5 points below the lens, only the metal head end of the biopsy forceps is out of the body.
(3) oropharyngeal esophagus:
For oropharyngeal part, NBI was used to consciously observe the larynx, exposing the suspected lesion of glottis and esophagus, washing, ventilation change, NBI, magnifying observation (avoiding iodine staining) for one square centimeter, taking 1-2 pieces.
(4) Stomach:
Open your stomach as much as you can, like a flat piece of paper
It is necessary to remove mucus from mucus surface, foam atrophic gastritis, especially the entire gastric body. Repeated observation on the bleeding place easily touched by endoscope
(5) selection of biopsy site of malignant ulcer:
There is a strong inflammatory reaction at the site of superficial hyperplasia. If the biopsy fails to reach the place where the depression is uplifted, it is not possible to take a biopsy (blood vessel). It is very important to bite the submucosa when the second piece fails to take the first piece after bleeding from the low position to the high position
(6) intestine:
Good bowel preparation - clean water before examination
The remaining liquid in the intestinal cavity was fully absorbed and the suspected lesions were repeatedly observed and sprayed with 0.2% indigo carmine.
(7) methods to improve the detection rate of enteroscopy:
Transparent cap can improve detection rate
For women over 50 years old, it is recommended to check the right colon twice. (the first white light and the second NBI) the appendix fossa should be observed carefully. If necessary, open the valve at the appendix mouth and return to the blind part for routine endoscopy and rectal routine endoscopy (if necessary, finger examination)
(8) colorectal polyps should not be easily biopsied:
The ultimate purpose of biopsy is not to diagnose but to treat the lesions that can be treated by endoscopy. Therefore, no biopsy is needed, which will lead to fibrosis and increase the positive rate of non lifting sign after EMR / ESD difficult biopsy. Endoscopic treatment of lesions, direct resection (treatment and diagnosis)
(9) Biopsy tips:
Before EMR of intestinal polyp, samples were taken by biopsy
Duodenal papilla should be treated first, then biopsied in the area suspected of early cancer, and some normal tissues should be biopsied in the same area at the same time, and the lower position should be taken first
(10) special precautions before biopsy:
1. Extraluminal compression
2. Submucosal tumor 3, gastric fundus lesion 4, esophageal solitary hemangioma (vein tumor, aneurysm) 5, gastric eminence of patients with pancreatic body and tail tumor 6, main and accessory papillae of duodenum
(11) the pathological diagnosis of biopsy is not absolute: the pathological physician should refer to the description of endoscopic performance when judging the subjective difference of lesions with a small amount of materials. If there are different cases between the endoscopic diagnosis and the pathological diagnosis, they need to be rechecked
(12) biopsy is a double-edged sword. Nonstandard biopsy can directly increase the probability of bleeding, increase the psychological burden of patients, and increase the negative rate of early cancer. Note: if the pathologist finds the intrinsic muscle layer after staining, it is necessary to remind the endoscopist to prevent the delayed perforation, improve the ability of endoscopic diagnosis, and reduce unnecessary biopsy. Biopsy increases bleeding.
The patient's psychological disturbance after biopsy should be considered.
The number of biopsies needs to be limited.
III. tunnel (deep excavation) biopsy technology
Diffuse infiltrative gastric cancer (leathery stomach)
Under the endoscopy of lymphoma, the mucosa is normal or only congested, swollen or eroded. Under the exploration of the endoscopy of ultrasound, above the thickening area of the intrinsic myometrium, the surface of the mucosa is cut by a needle knife, and the tissue is removed layer by layer
4. Large mucosal lesions can be detected by EMR
The ideal effect can be achieved by obtaining the deeper cross section and longitudinal section of the tissue
5. Tumor biopsy technique (ESD)
More emphasis on complete resection of lesions
Disadvantages, high cost, bleeding, perforation and other risks require high endoscopic level
6、 EUS-FNA guided by ultrasound
The real-time exploration function of EUS can accurately determine the location and nature of the lesions, on the basis of which fine-needle aspiration can be performed to obtain tissue.
The success or failure of EUS-FNA is closely related to the selection of puncture needle and the technical level of the operator. EUS-FNA is a high-level biopsy technology in the field of endoscopic interventional diagnosis and treatment.
6、 The difference between microscopic diagnosis and pathological diagnosis
Diagnostic criteria of endoscopy -- Japan
The criteria of pathological diagnosis --- malignant change is highly suspected under endoscopy in Europe and America, but the pathological findings indicate benign.
The following is the supplementary part of Director Fu Yiwei. It's very wonderful. I'd like to share it here and thank you! Fu Yiwei: Taizhou People's Hospital
Let's not talk about the big technology
Make the most basic diagnosis.
So in endoscopic diagnosis, biopsy is a basic skill, which can reflect the basic mirror control skills of the operating doctor. At the same time, it can also reflect that when the doctor is taking a biopsy, he should consider the characteristics and nature of the lesions to be biopsied, and pay attention to the location, angle and strength of the biopsy, so as to ensure the effectiveness of the tissue.
If the basic skills of biopsy are difficult to "point to where to hit", then I think the treatment is not good. After all, that would add a lot of insecurity. For example, bleeding and perforation can't be cleaned (in fact, hemostasis and suturing are only advanced techniques of biopsy forceps).
In the operation of biopsy, it is difficult to find the parallel direction of esophagus, fundus of stomach, anterior and posterior wall of gastric angle, antrum of stomach and posterior wall of body.
The esophagus is actually relatively simple. Some people may be used to stretch the biopsy forceps forward to take the target part
Let's watch a small video first. Please turn down the volume and ignore the background sound.
For esophageal biopsy, my personal operation points are: to extend the biopsy forceps, just extend the cup mouth of the biopsy forceps to an open state, and do not inject too much gas, otherwise it will be very shallow, only to the top layer.
The upper digestive tract should be taken as much as possible, even if your diagnosis is correct. Besides, this biopsy has no effect on the treatment. The colon is not the same, flat adenoma, not recommended biopsy but direct resection, because biopsy can lead to fibrosis, EMR can not lift. Even a single biopsy can have an impact. There is no influence on those who have a tie. Less than 2cm can be EMR.
Another biopsy under the cardia:
? this is the site of bleeding after several biopsies. Titanium clips can be used. If early cancer is suspected instead of APC, titanium clips will not interfere with the follow-up ESD
Thank you for your attention to gastrointestinal diseases: scientific, rigorous, professional and popular
Author: a Junren Dean of Datong County Hospital of traditional Chinese medicine, Xining City, Qinghai Province
Special thanks:
Dr. Tian ye, Yang Jian, Yu Guang, Fu Yiwei, Liu Hui, Cao Dafu and other gastroenterology experts! This article is from President a: a Junren
Wechat: dulin666, contribution email: wcb000666@163.com