32慢性胃炎chronicgastritis32慢性胃炎（慢性胃炎）

1/132慢性胃炎(chronicgastritis（32慢性胃炎（慢性胃炎）32慢性胃炎(chronicgastritis（32慢性胃炎（慢性胃炎）第三節(jié)慢性胃炎（慢性胃炎）慢性胃炎系指不同病因引起的各種慢性胃粘膜炎性病變，是一種常見病，也是部隊(duì)多發(fā)病之一，其發(fā)病率在各種胃病中居首位自纖維內(nèi)鏡廣泛應(yīng)用以來(lái)，對(duì)本病認(rèn)識(shí)有明顯提高。

慢性胃炎通常按其組織學(xué)變化和解剖部位加以分類，近年來(lái)還參照免疫學(xué)的改變，1982年在重慶召開的慢性胃炎會(huì)議擬訂了慢性胃炎的簡(jiǎn)略分類：

①淺表性胃炎，炎癥僅及胃粘膜的表層上皮，包括糜爛、出血、須指明是彌漫性或局限性，后者要注明病變部位。

②萎縮性胃炎，炎癥已累粘膜深處的腺體并引起萎縮，如伴有局部增生，稱萎縮性胃炎伴過(guò)形成（增生）。

③肥厚性胃炎，這類胃炎是否存在，因無(wú)上皮細(xì)胞肥大的證據(jù)，故尚有爭(zhēng)論。

慢性胃炎還可根據(jù)胃粘膜病變以下四個(gè)方面的特征，作更詳細(xì)的分類，包括，①慢性胃炎的部位，如胃體、胃竇、賁門等。

②慢性胃炎的性質(zhì)與分級(jí)，分為淺表性及萎縮性，后者又可分為輕、中、重度三級(jí)。

③胃炎活動(dòng)的程度，根據(jù)胃粘膜上皮的中性粒細(xì)胞浸潤(rùn)及退行性變，可定出活動(dòng)期或靜止期，活動(dòng)范圍又可分為彌漫性或局限性；④有無(wú)化生及其類型，化生分為腸腺化生（腸化）及假幽門腺化生，前者常見于萎縮性胃炎，偶可見于淺表性胃炎甚或正常粘膜，而后者僅見于萎縮性胃炎，是指胃體粘膜由胃竇粘膜所替代，常沿胃小彎向上移行，稱胃竇潛移。

1973年，思特里克蘭德及麥凱將萎縮性胃炎分為：

一型，抗壁細(xì)胞抗體（PCA）常陽(yáng)性，以胃體病變?yōu)橹?，血清胃泌素增高，可發(fā)生惡性貧血。

B型，PCA常陰性，以胃竇病變?yōu)橹?，血清胃泌素正?！?/p>

但據(jù)我國(guó)學(xué)者的研究，認(rèn)為上述兩型病變難以截然分開，主張還是按病變部位分類較合理，即分為萎縮性胃炎以胃竇為主，及萎縮性胃炎以胃體為主的兩類。

病因及發(fā)病機(jī)理慢性胃炎的病因和發(fā)病機(jī)理尚未完全闡明，可能與下列因素有關(guān)：

一、急性胃炎的遺患急性胃炎后，胃粘膜病變持久不愈或反復(fù)發(fā)作，均可形成慢性胃炎。

二、刺激性食物和藥物長(zhǎng)期服用對(duì)胃粘膜有強(qiáng)烈刺激的飲食及藥物，如濃茶、烈酒、辛辣或水楊酸鹽類藥物，或食時(shí)不充分咀嚼，粗糙食物反復(fù)損傷胃粘膜、或過(guò)度吸煙，菸草酸直接作用于胃粘膜所致。

三、十二指腸液的反流研究發(fā)現(xiàn)慢性胃炎患者因幽門括約肌功能失調(diào)，常引起膽汁反流，可能是一個(gè)重要的致病因素。

胰液中的磷脂與膽汁和胰消化酶一起，能溶解粘液，并破壞胃粘膜屏障，促使H＋及胃蛋白酶反彌散入粘膜，進(jìn)一步引起損傷。

由此引起的慢性胃炎主要在胃竇部。

胃一空腸吻合術(shù)患者因膽汁返流而致胃炎者十分常見。

消化性潰瘍患者幾乎均伴有慢性胃竇炎，可能與幽門括約肌功能失調(diào)有關(guān)煙草中的尼古丁能使幽門括約肌松弛，故長(zhǎng)期吸煙者可助長(zhǎng)膽汁反流而造成胃竇炎。

四、免疫因素免疫功能的改變?cè)诼晕秆椎陌l(fā)病上已普遍受到重視，萎縮性胃炎，特別是胃體胃炎患者的血液、胃液或在萎縮粘膜內(nèi)可找到壁細(xì)胞抗體；胃萎縮伴惡性貧血患者血液中發(fā)現(xiàn)有內(nèi)因子抗體，說(shuō)明自身免疫反應(yīng)可能是某些慢性胃炎的有關(guān)病因。

但胃炎的發(fā)病過(guò)程中是否有免疫因素參與，Inconclusive.Inaddition,atrophicgastritisofgastricmucosawithdiffuseinfiltrationoflymphocytesinvitrolymphoblastoidcelltransformationtestandleukocytemigrationinhibitiontestabnormalcellularimmuneresponsehasanimportantsignificanceintheoccurrenceofatrophicgastritis.Someautoimmunediseasessuchaschronicthyroiditisandhypothyroidismorhyperthyroidism,insulindependentdiabetes,chronicadrenalinsufficiencymaybeassociatedwithchronicgastritis,suggestingthatthediseasemayberelatedtoimmuneresponse.Five,1983WarrenandMarshallfoundthattheinfectionfactorsinpatientswithchronicgastritistogastricantrummucouslayerofepithelialcellsinsurfaceofHelicobacterpylori(Campylobacterpylori),thepositiveratewasashighas50-80%,reportsthebacteriumisfoundinnormalgastricmucosa.Wherethebacteriaareseeningastricmucosaininflammatorycellinfiltration,andthenumberofbacteriawaspositivelycorrelatedwiththedegreeof.Electronmicroscopyalsoshowedthatthenumberofepithelialcellsonthesurfaceoftheepithelialcellswasreducedorblunted.AntibodiesagainstHelicobacterpyloricanalsobefoundinthebloodandmucosaofthepatient.Thesymptomsandhistologicalchangescanbeimprovedorevendisappearedafterantibiotictreatment.Therefore,itisbelievedthatthisbacteriummaybeinvolvedinthepathogenesisofchronicgastritis.Butit’shardtosayforsure.PathologyAsuperficialgastritistogastricpitsandinflammationofmucouslayersurface.Thenakedeyeseesmucousmembranehyperemia,dropsy,orhastheexudation,mainlyseesinthestomachantrum,alsocanseeinthestomachbody,sometimesseesthesmallamountoferosionandthehemorrhage.Microscopically,therewereinfiltrationofneutrophils,lymphocytesandplasmacellsinthesuperficiallayerofthemembrane,andtheglandsinthedeeplayerremainedintact.Inaddition,somepatientshavemoreerosionsintheantrum,orareaccompaniedbyalargernumberofwarts,knownaschronicerosiveorverrucousgastritis.Two,atrophicgastritisinflammation,deepintothemucousmembrane,affectingthestomachgland,makeitatrophy,calledatrophicgastritis.Themucosaofthegastricmucosaisthinandthemucosafoldsflatordisappeared,whichcanbediffuseorlocalized.Microscopically,theglandsofthestomachdisappear,andtheindividualcancompletelydisappear.Thereisinfiltrationoflymphocytesandplasmacellsinthemucosaandsubmucosa.Sometimesmucosalatrophyhyperplasiacomplicatedbygastricfoveolarepithelium,causelocalmucouslayerbecomesthick,knownasatrophicgastritisformation.Ifinflammationspreadsextensively,destroyalargenumberofglands,makethewholestomachbodymucousmembraneatrophy,thin,callgastricatrophy.Atrophicgastritiscanoccurintestinalglandmetaplasiaandpseudopyloricmetaplasia,dysplasiaingastricpitsandintestinalepithelialhyperplasia(dysplasia).Dysplasiaisanabnormalmucosa,hasthecharacteristicsofatypicalcells,poorlydifferentiatedandmucousmembranestructuredisorder,thatislikelytobeprecancerouslesions.ClinicalmanifestationThediseaseisprogressingslowly,oftenrepeatedattacks,middle-agedandabovethegoodincidence,andwithageincreasedincidenceofdiseasetendency.Somepatientscannothaveanysymptoms,mostpatientscanhavevaryingdegreesofdyspepsiasymptoms,signsarenotobvious.Eachtypeofgastritishasdifferentmanifestations.Asuperficialgastritismayhavechronicirregularupperabdominalpain,abdominaldistension,belching,especiallyinthedietwasnotobvious,somepatientsmayhaveacidreflux,gastrointestinalbleeding,patientswithconfirmederosiveandgastroscopeVerrucousGastritis.Two,atrophicgastritisofdifferenttypes,differentpartsofitssymptomsarenotthesame.Lessgeneraldigestivetractsymptomsofgastricbodygastritis,sometimesappearanorexia,weightloss,glossitis,atrophyoftonguepapillae.Anemiaaccompaniedbyanemiaisrareinourcountry.Effectofatrophicgastritisofgastricantrumwhengastrointestinalsymptomsareobvious,especiallywithbilereflux,usuallypersistentupperabdominalpain,toeatafter,canvomitandsternumwithbilecontainingpainandburningsensation,sometimescanbeasmallamountofrecurrentuppergastrointestinalbleeding,andevenvomitingthissystem,gastricmucosalbarrierdamageandacutegastricmucosalerosioncausedby.Mostofthechronicgastritishavenoobvioussigns,andsometimestheyhavemildtendernessontheupperabdomen.LaboratoryandotherexaminationsAdeterminationofthegastricjuicesecretionofgastricjuiceanalysisbased(BAO)determinationoflargequantityofurinaryacidandincreasedhistamineorpentagastrinafterfive(MAO)andpeakurinaryacid(PAO)todeterminethegastricacidsecretion,helpsatrophicgastritisdiagnosisandtreatment.Superficialgastritis,gastricacidismorenormal,extensiveandseriousatrophicgastritis,gastricaciddecreased,especiallyinthestomachbodygastritisismoreobvious,stomachsinusitisisnormalormildobstruction.Superficial,suchasVerrucousGastritis,canalsohavegastricacidincreased.Two,theserologicaldetectionofchronicatrophicgastricinflammationofserumgastrinwasmoderatelyelevated,thisisduetolackofgastricacidsecretioninGcellsisnotinhibited.Ifthediseaseisserious,notonlyreducethesecretionofgastricacidandpepsinwasalsoreduced,intrinsicfactorsecretion,thusaffectingvitaminB12alsodecreased;serumPCAwasoftenpositive(morethan75%),chronicantralgastritisserumgastrindecreased,decreasedwithGcelldamageandserumPCA;alsohasacertainpositiverate(about30-40%).Three.Bariummealexaminationofgastrointestinaltractshoweddoublestructureofgastricmucosa,andtheatrophicmucosaofgastricmucosawasrelativelyflatanddecreased.TheX-raymanifestationsofgastricantrumgastritisshowedthattheantralmucosaofgastricantrumpresentedabluntserratedshapeandaspasticgastricantrum,orthepersistentstenosisoftheanteriorsegmentofthepylorusandthemucosalroughmass.TheX-rayfeaturesofVerrucousGastritischangeintoalarge,nodularfoldattheantrum,wheretherearebariumspotsinthecenterofsomefoldnodules.Four、gastroscopyandbiopsyarethemainmethodsforthediagnosisofchronicgastritis.Superficialgastritistogastricantrumismostobvious,morediffusegastricsurfacemucusincreased,withgraywhiteoryellowishwhiteexudate,mucosallesionsofredandwhiteormottled,likemeasleslikechange,sometimeshaveerosion.Atrophicgastritismucosashowedpaleorgrayishwhite,canalsoformaredandwhite,whitesag;plicasbecomefineorflat,duetothethinningofthemucousmembranecanseeavioletsubmucosalvascularlesions;diffuseormainlyinthegastricantrum,withproliferativechangesinthemucosalsurface,granularornodular.BiopsyspecimenshouldbeforpathologyandHelicobacterpyloridetection,ureasolutioncanbeafirstspecimeninphenolredinureasetestwaspositivein30-60minutessolutionturnspink,theotherwereculturedinspecialcultureliquid,inthemicroaerobicenvironment,thenweremadeintosections,staininginHEorWarthin-StarryorGieemsa.SectionsarevisibleinthemucouslayerintheformofmicropilesbendingisarrangedintheformofBacillus,filed.DiagnosisThesymptomsofchronicgastritishavenospecific,signsarefew,X-rayexaminationisusuallyhelpfultoexcludeotherstomachdiseases,sothediagnosisdependsongastroscopyandbiopsyofgastricmucosa.About5080%patientscanfindHelicobacterpyloriinthegastricmucosainchina.differentialdiagnosisFirst,thesymptomsofgastriccancer,chronicgastritis,suchaslossofappetite,epigastricdiscomfort,anemia,andsoon,asmallnumberofantralgastritisX-raysignsandgastriccancerisquitesimilar,specialattentionshouldbepaidtoidentify.Fiberopticgastroscopyandbiopsyarehelpfulformostpatients.Two,pepticulcerbothhavechronicupperabdominalpain,butmorethanpepticulcerabdominalregularity,cyclicalpainmainly,andchronicstomachpain,rarelyregular,andmainlyindigestion.IdentificationdependsonXraybariummealexaminationandgastroscopy.Three,chronicbiliarytractdiseasessuchaschroniccholecystitis,cholelithiasisoftenhavechronicrightupperabdominaldistension,belching,indigestionsymptoms,easilymisdiagnosedaschronicgastritis.However,thereisnoabnormalityinthegastrointestinalexamination.Four,otherdiseasessuchashepatitis,livercancerandpancreaticdiseasescanalsodelaythediagnosisandtreatmentbecauseofsymptomssuchaslossofappetiteandindigestion.Comprehensiveandsubtleexaminationandrelatedexaminationscanpreventmisdiagnosis.PreventionandcureMostsuperficialgastritiscanbereversedandasmallproportioncanbeconvertedtoatrophy.Atrophicgastritisgraduallyincreaseswithage,butcanalsobereversed.Therefore,thetreatmentofchronicgastritisshouldstartearlywithsuperficialgastritis,Atrophicgastritisshouldalsoadheretothetreatment.First,eliminatefactorsmaywipeoutallkindsofdisease,suchasdietandavoideatingdrugstrongstimulationofthegastricmucosa,quitdrinking.Payattentiontofoodhygieneandavoidovereating.Activetreatmentofchronicdiseasesofthemouth,noseandpharynx.Strengthenexercise,improvephysicalquality.Two,thepainmedicationavailableatropine,belladonnamixture,ofProulxBenSin,ofequalnitrogen.HyperaciditysuchasVerrucousGastritisofcimetidine,ranitidine,availableaminessuchasaluminumhydroxide.Ethyleneglycolisalocalanestheticthatinhibitsgastricantrumreleaseofgastrin