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胆囊内胃粘膜组织异位伴肠上皮化生与中度不典型增生:2例病例报告

2015-03-11 MedSci MedSci原创

图1组织学检查 图1(A)阿尔新蓝(Alcian blue)过碘酸雪夫氏染色(PAS)染色正常(箭头所示)和胆囊上皮化生。肠上皮化生的酸粘蛋白呈蓝色,而胃上皮化生(幽门型)的中性粘蛋白呈红色(X320)。(B)胆囊异位胃粘膜(胃体型),壁细胞(顶部)有一个大的锥体形结构,富含嗜酸性细胞质(苏木素-伊红

图1组织学检查
图1(A)阿尔新蓝(Alcian blue)过碘酸雪夫氏染色(PAS)染色正常(箭头所示)和胆囊上皮化生。肠上皮化生的酸粘蛋白呈蓝色,而胃上皮化生(幽门型)的中性粘蛋白呈红色(X320)。(B)胆囊异位胃粘膜(胃体型),壁细胞(顶部)有一个大的锥体形结构,富含嗜酸性细胞质(苏木素-伊红X480),同一区域(底部)Alcian blue-PAS(X480)染色。(C)胆囊息肉包含异位胃粘膜(苏木素-伊红X180)。
图1(A)阿尔新蓝(Alcian blue)过碘酸雪夫氏染色(PAS)染色正常(箭头所示)和胆囊上皮化生。肠上皮化生的酸粘蛋白呈蓝色,而胃上皮化生(幽门型)的中性粘蛋白呈红色(X320)。(B)胆囊异位胃粘膜(胃体型),壁细胞(顶部)有一个大的锥体形结构,富含嗜酸性细胞质(苏木素-伊红X480),同一区域(底部)Alcian blue-PAS(X480)染色。(C)胆囊息肉包含异位胃粘膜(苏木素-伊红X180)。

图2组织学检查
图2(A)上皮细胞轻度及局部中度不典型增生(箭头所示),发生在肠上皮化生(箭头)(Alcian blue-periodic-acid-SchiV (PAS)染色X320)(插图:幽门型化生上皮可见轻度不典型增生(苏木素 - 伊红X320)(B)该区域可见正常(箭头)和化生上皮(箭头)之间的过渡(苏木素 - 伊红X320),轻度不典型增生清晰可辩(插图:苏木素 - 伊红X850)。(C)接近正常胆囊上皮的胆管区可见肠上皮化生(箭头所示)(苏木素 - 伊红X540)。
图2(A)上皮细胞轻度及局部中度不典型增生(箭头所示),发生在肠上皮化生(箭头)(Alcian blue-periodic-acid-SchiV (PAS)染色X320)(插图:幽门型化生上皮可见轻度不典型增生(苏木素 - 伊红X320)(B)该区域可见正常(箭头)和化生上皮(箭头)之间的过渡(苏木素 - 伊红X320),轻度不典型增生清晰可辩(插图:苏木素 - 伊红X850)。(C)接近正常胆囊上皮的胆管区可见肠上皮化生(箭头所示)(苏木素 - 伊红X540)。

胃粘膜几乎遍及胃肠道的每一部分,从口腔到直肠,包括胆囊和肝脏。胆囊假幽门腺或幽门腺上皮化生最常见,66-84%的胆囊切除标本为上述情况。但胆囊肠上皮化生仅为12-52%,并经常与幽门化生有关,胆囊肠上皮化生可能是胆囊癌的病因之一。研究人员报道了2例罕见的胆囊胃粘膜异位病例,并对相关内容进行了文献综述。发表在2011年5月《Gut》上。

第一例病例,无胃粘膜异位症状,幽门腺和肠上皮不典型增生,化生,同时患有结肠腺癌。第二例病例,异位的胃粘膜在术前认为是一种良性胆囊息肉。迄今为止,还有其他3例胃粘膜异位被认为是腔内息肉样损害。

病例报告

患者1

患者男性,78岁,因结肠癌到我院就诊。手术时,胆囊触诊发现胆囊壁内硬性结节。同时进行胆囊切除术和结肠切除术。肉眼下胆囊标本3 x1.3x 0.8cm大小,并有一层光滑且发亮的浆膜。标本切开后,可见胆囊体胆囊壁增厚并伴有硬性结节,直径最大0.7cm。

组织学检查,提示结节位于固有层,由异位胃粘膜构成,包括胃体型和幽门型胃腺体,上覆粘膜增生。靠近异位粘膜处可见广泛的幽门腺化生和肠化生(图1A,B)并伴有化生上皮轻度—局部中度的不典型增生改变(图2A - C)。其它部分粘膜呈明显慢性胆囊炎的典型特征。未见胆结石。

患者2

患者女性,62岁,因模糊的消化不良症状和被形容为隐痛,有时向背部辐射,并伴有恶心,餐后腹部右上象限间歇性不适到我院就诊。患者很少呕吐。体格检查显示Murphy氏征阳性。经口胆囊胆道造影显示胆囊功能异常伴填充性缺损,这表明颈部及胆囊管交界处息肉。

超声可清晰显示交界部息肉。行胆囊切除术来治疗胆囊炎和胆囊息肉。胆囊切除标本8x2x0.9cm,可见一层光滑的灰白色浆膜。切开后可见胆囊颈部及胆囊管开口处可见红色-浅灰色息肉样结节,最大直径达0.8cm,其余部分为光滑的天鹅绒样绿色粘膜,厚度为0.4cm。未见胆结石。

组织学检查发现息肉样病变含有异位的胃粘膜,并伴顶叶和柱状粘液分泌细胞,与以前病例所见基本一致(图1B,C)。附近的胆囊粘膜呈慢性胆囊炎的典型特征。

讨论

胆囊出现胃粘膜异位非常罕见。这是1934年Egyedi报告以来首次发现。从1934年起,胃肠道各器官和部位包括舌,食管,会厌,小肠,阑尾,小肠,和胆囊在内均有异位的报道。世界范围内的文献调查显示包括本病例在内,共报告了45例,有趣的是,其他病例与我们的病例的临床和病理结果均不相同。

患者年龄,临床表现和症状,x线影像学和病理结果分布不均。6项延伸综述显示,性别分布上男女基本持平,女性稍稍占优,多见于6-77岁年龄段(大多数患者<30岁)。多数患者有右上腹痛,常为阵痛型,或模糊的不适,可能餐后伴有恶心,呕吐,或在某些病例可有梗阻性黄疸症状,年轻患者(小于25岁)的异位胃粘膜往往是唯一的病理所见且临床症状似乎要相对较短,甚至表现为急性,而在老年患者,可能在慢性胆囊炎和/或胆结石时偶然发现。几乎三分之一的患者可见胆结石。术中胆囊可呈正常的,交错的,结节状的,或多房性表现,或粘附于其他器官,胆囊壁呈限局性或弥漫性增厚。异位组织通常突入管腔,或无蒂,0.5至2.0cm不等,而且往往位于胆囊颈部或底部。

异位胃粘膜的特点是组织学可见胃底腺,包括顶叶和主细胞以及幽门腺,大多数研究人员报告称异位胃粘膜可包含以上所有成分(胃底型)。5例病例经证实可见APUD细胞。1例可见甲状腺组织,2例可见胰腺组织,3例胆囊壁可见消化道溃疡。

胚胎早期,胆囊源于肝原基。后者源于2.5mm胚胎前肠腹面,尾部距胃有些距离。在之后的发育中,二者均靠近原始横隔。因此,原始胃组织包埋或原始胆囊异位分化或化生分化可导致异位。

近来,在术前即可作出正确的胃异位诊断,通过使用过锝酸盐闪烁扫描检测Meckel憩室胃粘膜。胃异位鉴别诊断一般包括混合性胆结石或肿瘤(罕见),对病理学家来说,还包括肠化生(有时也呈息肉样特征),和幽门腺化生。

第一例患者,同时发现有胃体型胃粘膜异位与幽门型胃粘膜和结肠型肠化生。结肠型肠化生其余粘膜可见混合性病灶改变,---核质丰富且深染,呈轻度至中度假复层化以及有丝分裂----非常显著,慢性胆囊炎的病理特点非常明显。正如预期的那样,异位胃型粘膜经阿尔新蓝-PAS染色后呈红色,这表明为中性粘蛋白,而肠上皮化生的酸性粘蛋白与阿尔新蓝(图1A,B 2A)反应强烈。

目前已知胆囊癌,癌前上皮性或化生炎症性病变与胆结石之间关联密切,不同人种群之间的发病率也不同。发现胆结石伴发急性和黄色肉芽肿性胆囊炎,腺肌瘤,假幽门腺化生,肠化生,增生性息肉,不典型性增生,管状腺瘤,原位癌和浸润性癌出现较多,有趣的是,我们的患者未发现胆结石。此外,化生的程度似乎取决于患者的年龄。50岁以上患者出现胃窦型和肠上皮化生,似乎更多且更严重,我们研究的病例也是如此。此外,胆囊癌周围常见幽门化生型腺体增生。

第一例患者中胃异位与胆囊粘膜化生和不典型增生改变共存但完全缺乏临床症状可归因于异种移植性途径,而不是发育缺陷。已明确慢性炎症上皮呈化生改变。慢性炎症状态下,早期胆囊癌和上皮化生之间存在紧密联系。

然而,幽门型化生的致癌作用要比肠化生小,但Kijima和同事发现,胃粘膜上皮化生可导致胆囊早期微小癌病变。在这些病例中下,化生型癌在女性中较常见,存活率比非化生型癌要高。

由于p53蛋白在胆囊癌及其癌前病变的重要性,并且第一例患者因结肠癌而手术,所以对病变进行了免疫组化检测。使用了一种单克隆抗体(DO - 7; Dako公司M7001),1:50最佳稀释。使用SP法进行免疫组化染色,如前文所述。仅在结肠腺癌发现P53核免疫活性(分化良好,DukeA期)。约7-50%的结直肠肿瘤可检测到这些免疫活性,往往随着肿瘤分期增加而增加,似乎是结肠癌发生的一个晚期事件。

胆囊化生上皮和不典型性增生上皮病例中未见p53蛋白表达。 Wee和同事36曾报告称,与原位癌或浸润癌相比,胆囊不典型增生上皮明显的P53免疫染色较少见(28%)。但大多数的癌前病变与浸润癌有关。事实上,与皮损有关的7例原位癌中只有1例,18例不典型增生中仅有6例未发现毗邻浸润癌。此外,没有证据表明正常或胆囊化生上皮中p53过度表达。本文研究的病例均未发现化生P53蛋白表达,低度至中度不典型增生上皮与其他调查结果相一致。这可能提示p53基因异常,正如蛋白免疫染色证实所示,其不是胆囊癌发病中的最早期病变,或化生改变不是胆囊癌发病的先决条件。

相比之下,炎症期间胆囊上皮多向分化可解释我们的病例中观察到的病理变化。化生可以进展为不典型增生,从而经过多个步骤发展为腺癌,上述步骤可能源于遗传异常的蓄积。有趣的是,还观察到相反的结果,即,Kushima及同事在一系列研究中发现大多数的胆囊腺癌在免疫组化法和形态学均表现为胃型和/或肠型分化,这提示在胃肠分化的诱导下,胆囊腺癌出现并进展。有关这个问题的许多研究在文献中均有迹可循。研究人员认为,应对胆囊癌前病变进行进一步的分子生物学研究,以更好的理解其发病机制。

据研究人员所知,这是文献记载的第4起偶发病例,25首次证实包括化生和不典型性增生在内的上皮变化范围广泛。

第2例患者直到入院才出现症状。对泌酸壁细胞在症状出现中的作用甚是好奇。关于器官形成过程中的发育异常—即胆囊内胃黏膜形成,患者则可能出现临床活动性病灶,分泌酸并产生症状。如果是这样,病灶为什么会保持多年的静止状态呢?壁细胞数量减少,可能是一种解释,因为先前曾有报告过。研究的这例病例未见壁细胞减少。组织学发现,由于一种多能/多向间质细胞发育错误,而不是一种先天缺陷,因此有关的非特异性的临床指证和晚期症状是一种挑战,使我们推测胃粘膜异位代表着一种异种移植或化生过程。

总之,研究人员已经提出了有关胆囊无症状性胃粘膜异位并伴发幽门及肠上皮化生与不典型性增生的第一份报告,最初无临床症状可能源于化生,胆囊出现的胃粘膜可呈息肉状。这两个特点强调炎症在胆囊化生→增生→不典型性增生→胆癌变中的作用。此外,我们认为choristoma一词,从其词源学意义来说,也可以应用于异种移植病变,而不仅仅应用于先天组织发育错误。

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beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2016-08-20 doctorJiangchao

    继续学习

    0

  2. 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channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Fri Oct 16 16:33:00 CST 2015, time=2015-10-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1690945, encodeId=81ed16909450d, content=<a href='/topic/show?id=7adce62603e' target=_blank style='color:#2F92EE;'>#粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76260, encryptionId=7adce62603e, topicName=粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=090129165428, createdName=guoyibin, createdTime=Wed Dec 23 21:33:00 CST 2015, time=2015-12-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18954, encodeId=3b8b189547b, content=看起来很厉害的样子, beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2016-08-20 doctorJiangchao

    继续学习

    0

  3. 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beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, 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  4. 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channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Fri Oct 16 16:33:00 CST 2015, time=2015-10-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1690945, encodeId=81ed16909450d, content=<a href='/topic/show?id=7adce62603e' target=_blank style='color:#2F92EE;'>#粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76260, encryptionId=7adce62603e, topicName=粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=090129165428, createdName=guoyibin, createdTime=Wed Dec 23 21:33:00 CST 2015, time=2015-12-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18954, encodeId=3b8b189547b, content=看起来很厉害的样子, beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2015-05-25 3631184
  5. 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encryptionId=92698325555, topicName=胃粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=414632645823, createdName=3631184, createdTime=Mon May 25 16:33:00 CST 2015, time=2015-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1970308, encodeId=b29519e0308f5, content=<a href='/topic/show?id=bc8d202929a' target=_blank style='color:#2F92EE;'>#不典型增生#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20292, encryptionId=bc8d202929a, topicName=不典型增生)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5d70341, createdName=zhishijing, createdTime=Fri Jun 12 09:33:00 CST 2015, time=2015-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1898619, encodeId=3a55189861970, content=<a href='/topic/show?id=e5062028978' target=_blank style='color:#2F92EE;'>#不典型#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Fri Oct 16 16:33:00 CST 2015, time=2015-10-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1690945, encodeId=81ed16909450d, content=<a href='/topic/show?id=7adce62603e' target=_blank style='color:#2F92EE;'>#粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76260, encryptionId=7adce62603e, topicName=粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=090129165428, createdName=guoyibin, createdTime=Wed Dec 23 21:33:00 CST 2015, time=2015-12-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18954, encodeId=3b8b189547b, content=看起来很厉害的样子, 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replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
  6. 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encryptionId=92698325555, topicName=胃粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=414632645823, createdName=3631184, createdTime=Mon May 25 16:33:00 CST 2015, time=2015-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1970308, encodeId=b29519e0308f5, content=<a href='/topic/show?id=bc8d202929a' target=_blank style='color:#2F92EE;'>#不典型增生#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20292, encryptionId=bc8d202929a, topicName=不典型增生)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5d70341, createdName=zhishijing, createdTime=Fri Jun 12 09:33:00 CST 2015, time=2015-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1898619, encodeId=3a55189861970, content=<a href='/topic/show?id=e5062028978' target=_blank style='color:#2F92EE;'>#不典型#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Fri Oct 16 16:33:00 CST 2015, time=2015-10-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1690945, encodeId=81ed16909450d, content=<a href='/topic/show?id=7adce62603e' target=_blank style='color:#2F92EE;'>#粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76260, encryptionId=7adce62603e, topicName=粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=090129165428, createdName=guoyibin, createdTime=Wed Dec 23 21:33:00 CST 2015, time=2015-12-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18954, encodeId=3b8b189547b, content=看起来很厉害的样子, beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
  7. 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channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Fri Oct 16 16:33:00 CST 2015, time=2015-10-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1690945, encodeId=81ed16909450d, content=<a href='/topic/show?id=7adce62603e' target=_blank style='color:#2F92EE;'>#粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76260, encryptionId=7adce62603e, topicName=粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=090129165428, createdName=guoyibin, createdTime=Wed Dec 23 21:33:00 CST 2015, time=2015-12-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18954, encodeId=3b8b189547b, content=看起来很厉害的样子, beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2015-12-23 guoyibin
  8. 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channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Fri Oct 16 16:33:00 CST 2015, time=2015-10-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1690945, encodeId=81ed16909450d, content=<a href='/topic/show?id=7adce62603e' target=_blank style='color:#2F92EE;'>#粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76260, encryptionId=7adce62603e, topicName=粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=090129165428, createdName=guoyibin, createdTime=Wed Dec 23 21:33:00 CST 2015, time=2015-12-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18954, encodeId=3b8b189547b, content=看起来很厉害的样子, beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2015-03-26 lucas23

    看起来很厉害的样子

    0

  9. 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createdName=doctorJiangchao, createdTime=Sat Aug 20 21:25:00 CST 2016, time=2016-08-20, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1969111, encodeId=121f1969111ae, content=<a href='/topic/show?id=d9ed815204f' target=_blank style='color:#2F92EE;'>#肠上皮化生#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=118, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=81520, encryptionId=d9ed815204f, topicName=肠上皮化生)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=6c32257, createdName=DEXTER3139, createdTime=Sun Jan 10 01:33:00 CST 2016, time=2016-01-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1718816, encodeId=afa61e18816de, content=<a href='/topic/show?id=92698325555' target=_blank style='color:#2F92EE;'>#胃粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=83255, encryptionId=92698325555, topicName=胃粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=414632645823, createdName=3631184, createdTime=Mon May 25 16:33:00 CST 2015, time=2015-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1970308, encodeId=b29519e0308f5, content=<a href='/topic/show?id=bc8d202929a' target=_blank style='color:#2F92EE;'>#不典型增生#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20292, encryptionId=bc8d202929a, topicName=不典型增生)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5d70341, createdName=zhishijing, createdTime=Fri Jun 12 09:33:00 CST 2015, time=2015-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1898619, encodeId=3a55189861970, content=<a href='/topic/show?id=e5062028978' target=_blank style='color:#2F92EE;'>#不典型#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Fri Oct 16 16:33:00 CST 2015, time=2015-10-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1690945, encodeId=81ed16909450d, content=<a href='/topic/show?id=7adce62603e' target=_blank style='color:#2F92EE;'>#粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76260, encryptionId=7adce62603e, topicName=粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=090129165428, createdName=guoyibin, createdTime=Wed Dec 23 21:33:00 CST 2015, time=2015-12-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18954, encodeId=3b8b189547b, content=看起来很厉害的样子, beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]
    2015-03-26 acount

    这种诊断应该比较困难

    0

  10. 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encryptionId=92698325555, topicName=胃粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=414632645823, createdName=3631184, createdTime=Mon May 25 16:33:00 CST 2015, time=2015-05-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1970308, encodeId=b29519e0308f5, content=<a href='/topic/show?id=bc8d202929a' target=_blank style='color:#2F92EE;'>#不典型增生#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20292, encryptionId=bc8d202929a, topicName=不典型增生)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5d70341, createdName=zhishijing, createdTime=Fri Jun 12 09:33:00 CST 2015, time=2015-06-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1898619, encodeId=3a55189861970, content=<a href='/topic/show?id=e5062028978' target=_blank style='color:#2F92EE;'>#不典型#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=72, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=20289, encryptionId=e5062028978, topicName=不典型)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a12645, createdName=docwu2019, createdTime=Fri Oct 16 16:33:00 CST 2015, time=2015-10-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1690945, encodeId=81ed16909450d, content=<a href='/topic/show?id=7adce62603e' target=_blank style='color:#2F92EE;'>#粘膜#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=68, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=76260, encryptionId=7adce62603e, topicName=粘膜)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=090129165428, createdName=guoyibin, createdTime=Wed Dec 23 21:33:00 CST 2015, time=2015-12-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18954, encodeId=3b8b189547b, content=看起来很厉害的样子, beContent=null, objectType=article, channel=null, level=null, likeNumber=142, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=57081618975, createdName=lucas23, createdTime=Thu Mar 26 23:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=18896, encodeId=67df188969c, content=这种诊断应该比较困难, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7f0f106091, createdName=acount, createdTime=Thu Mar 26 00:23:00 CST 2015, time=2015-03-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1376970, encodeId=f6a013e697029, content=<a href='/topic/show?id=8ff8e0777c5' target=_blank style='color:#2F92EE;'>#病例报告#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=70777, encryptionId=8ff8e0777c5, topicName=病例报告)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=8143398, createdName=lily1616, createdTime=Fri Mar 13 11:33:00 CST 2015, time=2015-03-13, status=1, ipAttribution=)]

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