6.0 診断（Diagnosis）

[Last update 10.May 2002]

6.0 診断（Diagnosis）

6.1 扱われる範囲（Scope） This list of terms for each examination indicates the diagnosis, single or multiple that the endoscopist feels is most likely on the basis of macroscopic findings. This is not necessarily the final diagnosis, which takes into account the findings of any additional procedures performed such as biopsy/cytology. The diagnostic list has been split into two parts: (i) Main diagnoses, ordered by expected prevalence; (ii) Other (rarer) diagnoses listed alphabetically. The decision on to which list a particular diagnosis appears is based upon the expected frequency of this finding in a European context. This "diagnosis" could be used to implement a "conclusion" field within any report generated. Such a conclusion would be based on a synthesis of all of the findings recorded. This is particularly true when a number of different lesions are described, such as in inflammatory bowel diseases at colonoscopy. The Committee also recommends that it should be possible to record a "negative conclusion" as well as a positive one. It is often as important to record that a feature is not present as it is to describe that it is, for example, the failure to find any sign of bleeding when a patient presents with an apparent gastrointestinal bleed. It is suggested that it be possible to qualify a diagnosis by "certain", "suspected", "probably not present" and "definitely excluded". 6.2 上部消化管の診断用語（List of diagnosis for the upper gastrointestinal tract） 6.2.1 食道（Esophagus） The following terms shall be used to describe the diagnosis for the esophagus. Table 19.食道の診断(List of esophageal diagnosis)

`主診断 (Main Diagnoses)`		`属性 (Attribute)`
`正常(Normal)`		`疑い(Suspicion of)`
`逆流性食道炎(Reflux esophagitis)`		`確定(Established)`
`静脈瘤(Varices)`		`除外(Exclusion of)`
`良性狭窄(Benign stricture)`		`経過観察 (Follow-up of)`
`悪性腫瘍(Malignant tumor)`
`早期癌`	`Ⅰ`
	`Ⅱa`
	`Ⅱb`
	`Ⅱc`
	`Ⅲ`
`進行癌`	`1`
	`2`
	`3`
	`4`
	`5`
`バレット食道(Barrett's esophagus)`
`潰瘍(Ulcer)`
		`治療(Treatment of)`

`その他診断(Other Diagnoses)`
`アカラシア(Achalasia)`
`良性腫瘍(Benign tumor)`
`憩室(Diverticulum)`
`瘻孔(Fistula)`
`異物(Foreign body)`
`裂孔ヘルニア(Hiatus hernia)`
`Mallory-Weiss裂傷(Mallory-Weiss tear)`
`カンジダ性食道炎(Candidal(Monilial)esophagitis)`
`非逆流性食道炎 (Non reflux esophagitis)`
`ポリープ(Polyp)`
`術後(Post-operative appearance)`
`粘膜切除後癌遺残`
`粘膜切除後再発癌`
`硬化療法後の内視鏡所見` `(Post-sclerotherapy appearance)`
`瘢痕(Scar)`
`シャッキー輪(Schatzki ring)`
`粘膜下腫瘤(Submucosal tumor)`
`その他(記述する)`

6.2.2 胃（Stomach） The following terms shall be used to describe the diagnosis for the stomach. Table 20.胃の診断(List of stomach diagnosis)

`主診断 (Main Diagnoses)`		`属性 (Attribute)`
`正常(Normal)`		`疑い(Suspicion of)`
`胃症(Gastropathy:)`		`確定(Established)`
`びらん性(Erosive)`		`除外(Exclusion of)`
`発赤　(充血性) 　(Erythematous(hyperemic))`		`経過観察(Follow-up of)`
`肥厚性(Hypertrophic)`
`出血性(Hemorrhagic)`
`胃粘膜萎縮 (Gastric mucosal atrophy)`
`胃炎の疑い` `(Suspicion of gastritis(in this case the choices“Established…")`		`治療(Treatment of)`
`門脈圧亢進に伴う胃症` `(Portal hypertensive gastropathy)`
`急性胃粘膜病変`
`胃潰瘍(Gastric ulcer)`
`出血性胃潰瘍 (Bleeding gastric ulcer)`		`フォレスト分類による出血のタイプを加えることも可(In addition to the general attributes` `noted above the type of bleeding` `according to Forrest's classification may be included as modifiers for this` `diagnosis:)`
		`活動性脈動性(Type ⅠA:Active pulsating)` `活動性にじみ出る(TypeⅠB:Active oozing)` `露出血管(Type ⅡA:Visible vessel)` `ヘマチン/凝血塊` `(Type ⅡB:Black material/clot)` `出血所見なし(Type Ⅲ:No sign of bleeding)`
`吻合部潰瘍(Stomal ulcer)`
`悪性腫瘍:該当する場合は記述する:胃癌(Malignant tumor:Specify if relevant:Gastric carcinoma)`
`早期癌`	`Ⅰ`
	`Ⅱa`
	`Ⅱb`
	`Ⅱc`
	`Ⅲ`
`進行癌`	`1`
	`2`
	`3`
	`4`
	`5`
`ポリープ(Polyps)`
`腺腫`
`記述する(Specify)`

`その他診断(Other Diagnoses)`
`血管拡張症(Angioectasia)`
`良性腫瘍(Benign tumor)`
`原因不明の出血(Bleeding of unknown origin)`
`Dieulafoy病変 (Dieulafoy lesion)`
`憩室(Diverticulum)`
`粘膜切除後癌遺残`
`粘膜切除後再発癌`
`悪性リンパ腫`
`MALTリンパ腫`
`壁外性圧迫 (Extrinsic compression)`
`瘻孔(Fistula)`
`異物(Foreign body)`
`胃排出障害(Gastric retention)`
`H.pylori (Helicobacter pylori)`
`丘診状の胃症 (Papulous gastropathy)`
`寄生虫(Parasites(should be added to` `the list in some countries))`
`術後 (Post-operative appearance)`
`瘢痕(Scar)`
`粘膜下腫瘤(Submucosal tumor)`
`静脈瘤(Varices)`
`その他(記述する)`

6.2.3 十二指腸（Duodenum） The following terms shall be used to describe the diagnosis for the duodenum. Table21. 十二指腸の診断(List of duodenum diagnosis)

`主診断 (Main Diagnoses)`	`属性 (Attribute)`
`正常(Normal)`	`疑い(Suspicion of)`
`十二指腸症(Duodenopathy:)`	`確定(Established)`
`びらん性(Erosive)`	`除外(Exclusion of)`
`発赤(充血性)` 　　`(Erythematous(hyperemic))`	`経過観察(Follow-up of)`
`うっ血(Congestive)`	`治療(Treatment of)`
`出血性(Hemorrhagic)`
`十二指腸潰瘍 (Duodenal ulcer)`
`出血性十二指腸潰瘍` `(Bleeding duodenal ulcer)`	`上記の一般属性に加え､Forrest's分類に従い、この特有の用語に対して出血タイプの使用を行う｡(In addition to the` `general attribute here above, for this peculiar term, would be allowed the use of the type of bleeding according to Forrest's classification:)` `活動性脈動性` `(Type ⅠA:Active pulsating) 活動性にじみ出る (Type ⅠB:Active oozing) 露出血管(Type ⅡA:Visible vessel) ヘマチン/凝血塊 (Type ⅡB:Black material/clot) 出血所見なし (Type Ⅲ:No sign of bleeding)`
`十二指腸潰瘍による変形` `(Ulcerogenic deformed duodenum)`

`その他診断 (Other Diagnoses)`
`血管拡張症(Angioectasia)`
`良性腫瘍(Benign tumor)`
`原因不明の出血` `(Bleeding of unknown origin)`
`Brunner's腺の過形成` `(Brunner's gland hyperplasia)`
`セリアック病 (Coeliac disease)`
`クローン病 (Crohn's disease)`
`憩室(Diverticulum)`
`瘻孔(Fistula)`
`悪性腫瘍(Malignant tumor)`
`寄生虫(Parasite)`
`ポリープ(Polyp)`
`術後状態` `(Post-operative appearance)`
`瘢痕(Scar)`
`粘膜下腫瘍 (Submucosal tumor)`
`その他(記述する) (Other(specify))`

6.3 下部消化管の診断用語（List of lower gastrointestinal diagnosis） The following terms shall be used to describe the diagnosis for the colon. Table22. 大腸の診断(List of colon diagnosis)

`主診断 (Main Diagnoses)`		`属性 (Attribute)`
`正常(Normal)`		`疑い(Suspicion of)`
`ポリープ(Polyp(s))`		`確定(Established)`
`腺腫`
`悪性腫瘍(Malignant tumor:)`		`除外(Exclusion of)`
`原発性(Primary)`		`経過観察 (Follow-up of)`
`早期癌`	`Ⅰ`
	`Ⅱa`
	`Ⅱb`
	`Ⅱc`
	`Ⅲ`
`進行癌`	`1`
	`2`
	`3`
	`4`
	`5`
`再発､吻合物再発(Recurrent` `(post-operative/anastomotic))`
`潰瘍性大腸炎(Ulcertive colitis:)`
`寛解期(Quiescent)`
`活動性中度(Active moderate)`		`治療 (Treatment of)`
`活動性高度(Active severe)`
`クローン病(Crohn's disease:)`
`寛解期(Quiescent)`
`活動性中度(Active moderate)`
`活動性高度(Active severe)`
`非特異性腸炎(Unspecified colitis)`
`憩室症(Diverticulosis)`
`憩室炎(Diverticulitis)`
`放射線性腸炎/直腸炎`
`(Radiation(al)colitis/proctitis)`
`痔核(Hemorrhoids)`

`その他診断(Other Diagnoses)`
`血管拡張` `(Angioectasia(vascular abnormality))`
`原因不明ﾉ出血` `(Bleeding of unknown origin)`
`コンディロマ(Condylomata)`
`異物(Foreign body)`
`瘻孔(Fistula)`
`回腸炎(Ileitis)`
`虚血性大腸炎(Ischemic colitis)`
`悪性リンパ腫(Lymphoma)`
`MALTリンパ腫`
`メラノーシス(Melanosis)`
`寄生虫-国によってはリストへ追加されること(Parasites(should be added to the list in some countries))`
`大腸ポリポーシス(Polyposis coli)`
`嚢胞状大腸気腫症(Pneumatosis coli)`
`術後状態(Post-operative appearance)`
`術後狭窄(Post-operative stricture)`
`直腸炎(Proctitis)`
`偽膜性大腸炎(Pseudomembanous colitis)`
`孤立性潰瘍(Solitary ulcer)`
`脂肪腫(Lipoma)`
`カルチノイド`
`その他(記述する)(Other(specify))`

6.4 ERCPの診断用語（List of ERCP diagnosis） 6.4.1 膵（Pancreas） The following terms shall be used to describe the diagnosis for the pancreas. Table23. 膵の診断用語(List of pancreas diagnosis)

`主診断 (Main Diagnoses)`	`属性 (Attribute)`
`膵管造影失敗(Failed pancreatogram)`	`疑い(Suspicion of)`
`正常膵管像(Normal pancreatogram)`	`確診(Established)`
`慢性膵炎(Chronic pancreatitis)`	`除外(Exclusion of)`
`膵管狭細型慢性膵炎`
`膵腫瘍(Pancreatic tumor)`	`経過観察 (Follow-up of)`
`膵癌`
`粘液産生膵腫瘍`
`膵管内乳頭腫瘍`
`膵嚢胞(Pancreatic cyst)`
`乳頭狭窄(Papillary stenosis)`
`乳頭部腫瘍(Tumor Ampulla of Vater)`
	`治療(Treatment of)`
`その他の診断(Other Diagnoses)`
`膵･胆管合流異常(Abnormal` `biliary-pancreatic junction)`
`輪状膵(Annular pancreas)`
`膵管非癒合(Pancreas divisum)`
`膵液瘻(Pancreatic duct fistula)`
`膵石(Pancreatic stone)`
`寄生虫(Parasites)`
`その他記述する(Other(specify))`

6.4.2 胆道（Biliary tract） The following terms shall be used to describe the diagnosis for the biliary tract. Table24. 胆道の診断用語(List of biliary tract diagnosis)

`主診断 (Main Diagnoses)`	`属性 (Attribute)`
`胆道造影失敗(Failed cholangiogram)`	`疑い(Suspicion of)`
`正常胆道像(Normal cholangiogram)`	`確診(Established)`
`正常胆摘後胆道像(Normal post-cholecystectomy cholangiogram)`	`除外(Exclusion of)`
`正常乳頭切開後胆道像(Normal post-sphincterotomy cholangiogram)`	`経過観察(Follow-up of)`
`胆道結石(Cholelithiasis)`
`総胆管結石(Choledocholithiasis)`
`胆嚢結石(Cholecystolithiasis)`
`肝内結石(Hepatic lithiasis)`	`治療(Treatment of)`
`胆嚢管結石(Cystic duct lithiasis)`
`遺残胆嚢管結石(Cystic stump lithiasis)`
`Mirizzi症候群(Mirizzi syndrome)`
`胆道腫瘍(Biliary tumor)`
`肝内胆管腫瘍`
`肝外胆管腫瘍`
`総胆管腫瘍(Main Bile duct tumor)`
`Klatzkin腫瘍(Klatzkin tumor)`
`胆嚢腫瘍(Gallbladder tumor)`
`胆嚢ポリープ`
`胆嚢腺筋腫症`
`乳頭狭窄(Papillary stenosis)`
`乳頭部腫瘍(Ampullary tumor)`
`ステント閉塞(Stent occlusion)`

`その他の診断(Other Diagnoses)`
`膵胆管合流異常 (Abnormal biliary-pancreatic junction)`
`胆管瘻(Bile duct fistula)`
`胆管閉塞(Bile duct occlusion)`
`胆汁漏出(Bile leak)`
`胆管狭窄(Biliary stricture)`
`Caroli病(Caroli's disease)`
`総胆管嚢腫(Choledochal cyst)`
`総胆管瘤(Choledochocele)`
`肝硬変(Cirrhosis)`
`血液胆汁(Hemobilia)`
`乳頭狭窄(Papillary stenosis)`
`寄生虫(Parasites)`
`硬化性胆管炎(Sclerosing cholangitis)`
`Sump症候群(Sump syndrome)`
`化膿性胆管炎` `(Suppurative cholangitis)`
`胆嚢腫瘍(Tumor of the gallbladder)`
`その他:記述する(Other(specify))`