臨床の場における上部消化管スクリーニング法―内視鏡の立場より

Screening of the Upper Gastrointestinal Tract Diseases in Practice: Endoscopy as the first examination

　われわれは1973年に2,500回の細径前方視鏡を用いた検査成績を報告して，これからの上部消化管の検査は，胃透視→内視鏡→生検という習慣を脱却して，内視鏡を中心に行うべきでなかろうかとの見解を述べた．この方針で診療を続け，1976年から1981年までの6年間の細径前方視鏡を用いた検査は16,318件に及び，同期間の胃透視の6,838件の2.39倍に達している．本特集号に執筆の機会を与えていただいたので，われわれの資料をできる限り詳しく分析して，反省を加えた．

　Since 1976, we had been gradually changing the “fluoroscopy first”policy in the examination of the upper GI tract to “endoscopy first”one. Its influence on diagnosis was investigated.

　Age, sex and symptoms matched 910 pairs were made from fluoroscopy-first group in 1976 and endoscopy-first one in 1978. For endoscopy a skinny endoscope was used and biopsy was performed when it was indicated. Over two years follow-up was performed in 61% of the cases. Overall usefulness of endoscopy was same to, or rather higher than that of fluoroscopy. The detection of esophageal varices, esophagitis, early gastric cancer and erosions was higher in endoscopy and that of diverticulum and deformity in fluoroscopy. Significantly high rate of false positive diagnosis was present in fluoroscopy.

　In the next, 271 cases of esophageal and gastric cancer newly detected in our department between 1972 to 1981 were divided into two groups depending on whether they underwent fluoroscopy or endoscopy as the first examination. The superficial esophageal cancer was only detected in the endoscopy group. The frequency of early gastric cancer was significantly higher in the endoscopy group (28% vs 43%). Early gastric cancer in the proximal one third of the stomach was present only in the endoscopy group. In the endoscopy group the diagnosis was established in 96% by the first examination but in the fluoroscopy one further examination was necessary in 37%.

　Nine gastric cancers were overlooked by endoscopy and five foci were false negative in biopsy. Most of them were located at the oral side above the gastric angle. The gastric juice should be sucked before examination. Very careful investigation is requested in cardiac area. We stress to observe each part of the gastric corpus from two or more different directions. Some scirrhous cancer was difficult to be diagnosed.

　In conclusion fluoroscopy of the upper GI tract must be replaced by endoscopy with a skinny instrument such as GIF-P3 or its equivalent. Medico-economic effect which may be provoked by this change must be carefully considered.