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},
"code": "C15",
"name": "Рак пищевода",
"icd_name": "Рак пищевода",
"gender": 0,
"age_min": 50,
"age_max": 60,
"cause": [
3,
0
],
"periodicity": 4,
"slug": "c15_rak_pischevoda",
"lead": "это злокачественная опухоль, развивающаяся из клеток, покрывающих слизистую оболочку пищевода.",
"description": " Рак пищевода развивается наиболее часто из эпителиальных клеток его слизистой оболочки (карцинома), реже наблюдается плоскоклеточный рак, редко – аденокарцинома, крайне редко – другие виды злокачественных новообразований.",
"etiology": "<p>В развитии рака пищевода ведущую роль играет хроническое <a href=\"/symptom/vospalenie/\" title=\"Перейти на страницу симптома воспаление\">воспаление</a> слизистой оболочки в результате механического, термического или химического раздра¬жения.</p>\r\n<p>К основным факторам риска рака пищевода относят:</p>\r\n<ul>\r\n<li>курение табака</li>\r\n<li>злоупотребление крепкими спиртными напитками</li>\r\n<li>химический ожог пищевода (уксусная кислота, щелочи)</li>\r\n<li>хронический заброс желудочного содержимого в пищевод (гастроэзофагеальная рефлюксная болезнь)</li>\r\n<li>Предраковые заболевания:\r\n<ul>\r\n<li>пищевод Барретта - состояние, при котором клетки плоского эпителия слизистой оболочки пищевода замещаются клетками кишечного типа. Обычно это происходит в результате длительного заброса желудочного сока и желчи в пищевод (врожденный короткий пищевод, грыжа пищеводного отверстия диафрагмы, недостаточность мышечного клапана между пищеводом и желудком – нижнего пищеводного сфинктера).</li>\r\n<li>Ахалазия пищевода – нервно-мышечное заболевание, при котором нарушается моторика стенок пищевода и способность нижнего пищеводного сфинктера расслабляться при глотании. В результате пища подолгу задерживается в расширенном пищеводе, не проходя в желудок.</li>\r\n<li>Рубцовая <a href=\"/symptom/stenoz/\" title=\"Перейти на страницу симптома стеноз\">стриктура</a> – рубцовое <a href=\"/symptom/stenoz/\" title=\"Перейти на страницу симптома стеноз\">сужение</a> пищевода после перенесенного химического ожога или в результате хронического воспаления</li>\r\n</ul>\r\n</li>\r\n<li>частое употребление очень горячей пищи и напитков (термический ожог)</li>\r\n<li>ожирение</li>\r\n<li>пожилой возраст</li>\r\n<li>мужской пол</li>\r\n</ul>",
"pathogenesis": "",
"diagnostics": "<p>При развитии дисфагии (нарушений проглатывания и продвижения пищи) диагностическое значение имеет оценка ее выраженности и локализации. Наличие дисфагии дает основание заподозрить рак пищевода. Основными методами диагностики являются рентгенологический и эндоскопический с обязательным морфологическим исследованием образцов тканей из измененных участков слизистой оболочки пищевода.</p>\r\n<p> Рентгенография пищевода</p>\r\n<p>При рентгенографии пищевода, прежде всего, проводят исследование функции глотания с использованием рентегноконстрастных веществ (сульфата бария) различной консистенции, за исключением выраженного сужения просвета пищевода, когда необходимо использовать водорастворимый контрастный препарат.. Это позволяет выявить, где наблюдаются нарушения: в глотке или в пищеводе. Если причина дисфагии в нарушении функции пищевода, то следующим этапом обследования должна быть оценка того, какая пища ее вызывает: только твердая или твердая и жидкая. <a href=\"/symptom/zatrudnenie_glotaniya/\" title=\"Перейти на страницу симптома Затруднение глотания\">Нарушение глотания</a> твердой пищи предполагает наличие механической непроходимости пищевода и может быть обусловлено ранними проявлениями целого ряда заболеваний. Пожилой возраст, отсутствие изжоги, <a href=\"/symptom/anormalnaya_poterya_vesa/\" title=\"Перейти на страницу симптома Анормальная потеря веса\">снижение массы тела</a> – это факторы, помогающие диагностировать опухоль.</p>\r\n<p>Рентгенография позволяет получить информацию не только о локализации, протяженности поражения, но и о состоянии органа в целом. Так как в вертикальном положении контрастное вещество быстро эвакуируется из пищевода, рентгенологическое исследование выполняют в положении пациента стоя и лежа.</p>\r\n<p>Эндоскопическое исследование</p>\r\n<p>На ранних этапах заболевания, когда оно протекает бессимптомно, обнаружить его можно только при эндоскопическом обследовании. Эта диагностическая процедура является методом, позволяющим помимо визуального осмотра слизистой пищевода взять для исследования ее часть для морфологического и гистологического исследования. В последние годы широко используется эндоскопическая ультрасонография, которая дает возможность оценить распространение опухоли в стенке пищевода и состояние прилежащих тканей, а также регионарных лимфатических узлов. Применение этого метода диагностики значительно повысило частоту выявления ранних форм рака пищевода, в том числе локализующихся только в пределах слизистой оболочки (рак in situ).</p>\r\n<p>Отдаленные метастазы рака пищевода определяются при ультразвуковом исследовании и рентгеновской компьютерной томографии. При подозрении на прорастание опухоли в соседние структуры, прежде всего в бронхиальное дерево, необходимо провести исследование верхних дыхательных путей, в том числе бронхоскопию с морфологичеким изучением промывных вод бронхов и биопсийного материала.</p>",
"treatment": "<p>Основными методами лечения рака пищевода являются хирургические и все более широко применяемые эндоскопические.</p>\r\n<full></full>\r\n<p>Хирургические методы лечения</p>\r\n<p>В лечении рака пищевода основное значение придается хирургическим методам, а также комбинации лучевой терапии и оперативного вмешательства. Очередность сочетания, объем лучевой нагрузки и комбинация ее с оперативным вмешательством зависят от стадии заболевания и локализации опухоли.</p>\r\n<p>Основные виды хирургических операций:</p>\r\n<p>• Экстирпация пищевода – радикальная операция, предусматривающая удаление пораженного пищевода вместе с регионарными лимфатическими узлами и окружающей жировой клетчаткой. Выполнение такой операции возможно не более чем у 5% больных вследствие поздней диагностики рака, пожилого возраста пациентов и наличия у них тяжелых сопутствующих заболеваний. Она очень травматична, в последующем пациенты нуждаются в проведении реконструктивной пластики пищевода.</p>\r\n<p>• Операция Гарлока (резекция нижней трети пищевода, части желудка с малым сальником и формирование пищеводно-желудочного анастомоза) выполняется при опухолях в нижней трети пищевода и в области его перехода в желудок (кардии). Результаты этого вида хирургического лечения лучше, чем при экстирпации пищевода. </p>\r\n<p>• Операция Льюиса – одномоментная субтотальная резекция пищевода и пластика его желудком. Выполняется при раке среднегрудной части пищевода.</p>\r\n<p>Эндоскопические методы лечения</p>\r\n<p>• Эндоскопическая резекция слизистой пищевода. Во время этого вмешательства под опухоль в подслизистый слой вводится физиологический раствор для «приподнимания» зоны поражения, которая затем удаляется специальной полипэктомической петлей.</p>\r\n<p>• Фотодинамическая нетермическая деструкция проводится с использованием лазера, спектр излучения которого находится в зоне наибольшей чувствительности используемого фотосенсибилизирующего препарата. Фотосенсибилизатор вводится за 2–3 суток перед манипуляцией, за это время он накапливается в клетках пораженной области слизистой и под влиянием излучения активируется, разрушая опухолевые клетки.</p>\r\n<p>• Лазерная деструкция выполняется световодом, вводимым через эндоскоп. Из-за невозможности гистологического исследования тканей подобный вид лечения используется у пациентов, которым невозможно радикальное хирургическое лечение и для прогноза заболевания которых оценка глубины прорастания опухоли не имеет определяющего значения.</p>\r\n<p>• Дилатация (расширение) суженной области пищевода выполняется специальными типами бужей (медицинские инструменты цилиндрической формы для введения в трубчатые внутренние органы) или баллонных катетеров (катетеры с надувающимися воздухом и увеличивающимися в объеме баллонами). Данные манипуляции используются при наличии опухолей, суживающих просвет пищевода. Подобное лечение имеет непродолжительный эффект и часто используется как первый этап перед применением других эндоскопических методов лечения.</p>\r\n<p>• Реканализация просвета пищевода применяется при полностью или частично перекрытом просвете пищевода, чаще в верхней его трети. Для этих целей можно проводить курсовое лазерное лечение для деструкции (выжигания) опухоли. Повторные процедуры обычно проводятся через 1–2 недели (после отторжения некротичесих масс), курс состоит из 2–4 сеансов лазерного воздействия. Также опухоль можно разрушить термическим воздействием полипэктомической петлей или электрокоагуляцией, выполняемой моно- или биполярным электродом. Для разрушения опухоли применяется также 96° этиловый спирт, вводимый инъекционной иглой через канал эндоскопа 2–3 раза с интервалом 5–7 дней. Хорошие функциональные результаты при использовании различных методов реканализации (возможность питаться через рот плотной и кашицеобразной пищей) достигаются в среднем у 75% пациентов.</p>\r\n<p>• Эндопротезирование выполняется для закрепления эффекта реканализации, восстановлении нормального способа питания через рот, а также для устранения сообщения пищевода и дыхательных путей при наличии пищеводно-трахеальных или пищеводно-бронхиальных свищей. В качестве протезов применяются трубчатые пластиковые протезы и металлические саморасправляющиеся стенты.</p>\r\n<p>Лучевая терапия</p>\r\n<p>Лучевая терапия при операбельном раке пищевода проводитсякурсами до и после операции. До операции лучевая терапия выполняется при недифференцированных и инфильтративной формах рака, а также при локализации опухоли в средней трети пищевода, то есть в анатомической области, где сложно выполнить радикальное удаление опухолевых тканей. После операции она проводится, если при хирургическом вмешательстве не удалось радикально убрать опухоль или если существует риск обсеменения окружающих тканей раковыми клетками. При неоперабельных опухолях лучеваятерапия используется в составе комплексных схем лечения с различными химиотерапевтическими препаратами. Например, применение комбинации цисплатины и 5-фторурацила в сочетании с лучевой терапией в дозе 50 Гр на область опухоли почти в 20% случаев приводит к полной регрессии опухоли.</p>\r\n<p>Химиотерапия</p>\r\n<p>Рак пищевода – опухоль, чувствительная к химиотерапии. Эффективность монотерапии при лечении такими препаратами, как фарморубицин, виндезин, блеомицин, митомицин, 5-фторурацил составляет от 15 до 20%. Использование схем комбинированной терапии с включением в их состав цисплатнины, позволяет достигнуть 40% эффективности при диссеминированном и до 70% при местнораспространенном опухолевом процессе.</p>",
"prevention": "<p>Основным методом профилактики рака пищевода является выделение групп риска и обязательная диспансеризация пациентов, входящих в них. Для этого необходимо, чтобы врачи поликлиник проявляли онконастороженность при наблюдении пациентов с хроническим эзофагитом, пищеводом Баррета, стриктурами пищевода, ахалазией кардии и грыжей пищеводного отверстия диафрагмы, а сами пациенты не пренебрегали регулярными диагностическими обследованиями.</p>",
"clinical_picture": "<p>Основным проявлением рака пищевода является постепенно нарастающая <a href=\"/symptom/zatrudnenie_glotaniya/\" title=\"Перейти на страницу симптома Затруднение глотания\">дисфагия</a> (затрудненное прохождение пищи по пищеводу). Вначале пациенты отмечают задержку при приеме грубой и сухой пищи и вынуждены запивать ее жидкостью, в дальнейшем нарушается прохождение кашицеобразной пищи и, наконец, приходит момент, когда больной не в состоянии проглотить даже воду.Другие симптомы, на которые следует обратить внимание</p>\r\n<ul>\r\n<li>боли при глотании</li>\r\n<li>боли за грудиной или между лопатками</li>\r\n<li>похудание</li>\r\n<li>осиплость голоса</li>\r\n<li>поперхивание и <a href=\"/symptom/kashel/\" title=\"Перейти на страницу симптома Кашель\">кашель</a> при приеме пищи</li>\r\n<li>изжога</li>\r\n<li>появление увеличенных лимфатических узлов в надключичной области или на шее</li>\r\n</ul>",
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