本文对我院2021年结肠腺瘤的诊断实践进行总结分析，为结肠腺瘤的临床诊断及编码提供数据以供同行参考。
方法：根据1698例病历的病案号检索患者电子病历首页的诊断及病理形态学编码(病案科质控编码前)，对病理诊断及临床诊断的符合程度进行描述性统计分析。结果：在结肠管状腺瘤或伴低级别上皮内瘤变病例中，医生准确诊断为良性肿瘤占54.90%。未区分肿瘤性质，笼统诊断为息肉占41.60%。漏诊断良性肿瘤占2.60%。将多发管状腺瘤诊断为腺瘤样息肉病占0.91%。在结肠管状腺瘤伴高级别上皮内瘤变病例中，医生错误诊断为良性肿瘤占38.22%；笼统诊断为息肉占36.31%，与管状腺瘤或伴低级别上皮内瘤变诊断为息肉比例相近。漏诊断为原位癌占1.27%。将管状腺瘤伴高级别上皮内瘤变诊断为腺瘤样息肉病占3.19%。准确诊断为原位癌占14.65%。将动态未定肿瘤诊断为结肠肿物或占位各占3.19%。结论：上述研究提示，临床医生对腺瘤同时伴高级别上皮内瘤变的患者诊断上不能用结肠息肉笼统替代，更不能诊断为结肠良性肿瘤，应准确诊断为结肠原位癌。
Abstract：
Objective: In view of the inconsistent understanding of adenoma with high-grade dysplasia in clinical practice in the medical community, this paper summarized and analyzed the diagnostic practice of colorectal adenoma in our hospital in 2021, so as to provide data for the clinical diagnosis and coding of colorectal adenoma for reference.
Methods: According to the medical record numbers of 1698 cases, the diagnostic and pathologic codes of patients' electronic medical records were retrieved (before the quality control codes of the medical records department), and the coincidence degree of pathological diagnosis and clinical diagnosis was analyzed descriptively.
Results: In THE cases of COLonic tubular adenoma or low-grade intraepithelial neoplasia, 54.90% of the cases were diagnosed as benign. The nature of the tumor was not distinguished. 41.60% of the patients were diagnosed with polyps. Missing diagnosis of benign tumors accounted for 2.60%. Multiple tubular adenomas were diagnosed as adenomatous polyposis in 0.91% of cases.
In the cases of colon tubular adenoma with high-grade intraepithelial neoplasia, 38.22% were misdiagnosed as benign tumors. The total diagnosis of polyps was 36.31%, which was similar to that of tubular adenoma or low-grade intraepithelial neoplasia. Missed diagnosis of carcinoma in situ accounted for 1.27%. Tubular adenoma with high-grade intraepithelial neoplasia was diagnosed as adenomatous polyposis in 3.19% of cases. The accurate diagnosis of carcinoma in situ was 14.65%. The diagnosis of the dynamic undetermined tumor as colonic mass or mass accounted for 3.19%, respectively.
Conclusion: These studies suggest that the clinician should not replace the adenoma with colonic polyps in the diagnosis of high-grade intraepithelial neoplasia, let alone the diagnosis of a benign colon tumor, should accurately diagnose the colonic carcinoma in situ.
关键词：结肠腺瘤 临床诊断 低级别上皮内瘤变 高级别上皮内瘤变 原位癌
引言：
在结肠镜检查中，腺瘤的发病率为24%～48%。大部分结直肠癌是由腺瘤发展而来，随着结肠镜技术的发展，越来越多的结直肠瘤在早期得到诊治。结直肠肿瘤内镜切除标本的精准病理评估，尤其是恶性息肉的精准评估，对患者的后续治疗、预后起至关重要的作用[1]。结肠息肉的分类方案较多，由于肿瘤性息肉恶变率较高，而非肿瘤性息肉基本不恶变，故息肉分类的关键是要把肿瘤性和非肿瘤性息肉分开，以便于临床治疗措施的选择和治疗效果比较。WHO第四版消化系统肿瘤病理分型中认为，具有腺癌形态学特点的病变，仅局限于黏膜层时，切除后并无转移后风险，因为干净切除后病变为治愈性，应诊断为“高级别异型增生”或“黏膜内癌”。避免不适当的过度治疗。但日本结直肠癌协会编写的治疗指南推荐常规应用“黏膜内腺癌”诊断及相关治疗。我国颁布的疾病分类与代码临床版2.0使用的病理形态学编码是“xx原位腺癌”。鉴于目前医学界对于腺瘤伴高级别异型增生在临床实践中认识不一致，本文对我院2021年结肠腺瘤的诊断实践进行总结分析，为结肠腺瘤的临床诊断及编码提供数据以供同行参考。
