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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）第三节慢性胃炎（慢性胃炎）慢性胃炎系指不同病因引起的各种慢性胃粘膜炎性病变，是一种常见。彩遣慷佣喾⒉≈，其发病率在各种胃病中居首位自纤维内镜广泛应用以来，对本病认识有明显提高。

慢性胃炎通常按其组织学变化和解剖部位加以分类，近年来还参照免疫学的改变，1982年在重庆召开的慢性胃炎会议拟订了慢性胃炎的简略分类：

①浅表性胃炎，炎症仅及胃粘膜的表层上皮，包括糜烂、出血、须指明是弥漫性或局限性，后者要注明病变部位。

②萎缩性胃炎，炎症已累粘膜深处的腺体并引起萎缩，如伴有局部增生，称萎缩性胃炎伴过形成（增生）。

③肥厚性胃炎，这类胃炎是否存在，因无上皮细胞肥大的证据，故尚有争论。

慢性胃炎还可根据胃粘膜病变以下四个方面的特征，作更详细的分类，包括，①慢性胃炎的部位，如胃体、胃窦、贲门等。

②慢性胃炎的性质与分级，分为浅表性及萎缩性，后者又可分为轻、中、重度三级。

③胃炎活动的程度，根据胃粘膜上皮的中性粒细胞浸润及退行性变，可定出活动期或静止期，活动范围又可分为弥漫性或局限性；④有无化生及其类型，化生分为肠腺化生（肠化）及假幽门腺化生，前者常见于萎缩性胃炎，偶可见于浅表性胃炎甚或正常粘膜，而后者仅见于萎缩性胃炎，是指胃体粘膜由胃窦粘膜所替代，常沿胃小弯向上移行，称胃窦潜移。

1973年，思特里克兰德及麦凯将萎缩性胃炎分为：

一型，抗壁细胞抗体（PCA）常阳性，以胃体病变为主，血清胃泌素增高，可发生恶性贫血。

B型，PCA常阴性，以胃窦病变为主，血清胃泌素正常。

但据我国学者的研究，认为上述两型病变难以截然分开，主张还是按病变部位分类较合理，即分为萎缩性胃炎以胃窦为主，及萎缩性胃炎以胃体为主的两类。

病因及发病机理慢性胃炎的病因和发病机理尚未完全阐明，可能与下列因素有关：

一、急性胃炎的遗患急性胃炎后，胃粘膜病变持久不愈或反复发作，均可形成慢性胃炎。

二、刺激性食物和药物长期服用对胃粘膜有强烈刺激的饮食及药物，如浓茶、烈酒、辛辣或水杨酸盐类药物，或食时不充分咀嚼，粗糙食物反复损伤胃粘膜、或过度吸烟，菸草酸直接作用于胃粘膜所致。

三、十二指肠液的反流研究发现慢性胃炎患者因幽门括约肌功能失调，常引起胆汁反流，可能是一个重要的致病因素。

胰液中的磷脂与胆汁和胰消化酶一起，能溶解粘液，并破坏胃粘膜屏障，促使H＋及胃蛋白酶反弥散入粘膜，进一步引起损伤。

由此引起的慢性胃炎主要在胃窦部。

胃一空肠吻合术患者因胆汁返流而致胃炎者十分常见。

消化性溃疡患者几乎均伴有慢性胃窦炎，可能与幽门括约肌功能失调有关烟草中的尼古丁能使幽门括约肌松弛，故长期吸烟者可助长胆汁反流而造成胃窦炎。

四、免疫因素免疫功能的改变在慢性胃炎的发病上已普遍受到重视，萎缩性胃炎，特别是胃体胃炎患者的血液、胃液或在萎缩粘膜内可找到壁细胞抗体；胃萎缩伴恶性贫血患者血液中发现有内因子抗体，说明自身免疫反应可能是某些慢性胃炎的有关病因。

但胃炎的发病过程中是否有免疫因素参与，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.Ethyleneglycolisalocalanestheticthatinhibitsgastricantrumreleaseofgastrinandreducesgastricacid.Thelackofgastricacidornoacidcangive1%dilutehydrochloricacidorpepsinmixture,withindigestioncanbecombinedwithMultienzymeTablets,pancreatintabletszhuxiaohuayao.BiopsyofgastricmucosaHelicobacterpyloriplusserviceantibioticssuchasstreptomycin,tetracycline,oxytetracycline,furazolidone,gentamicin,kanamycin,neomycinetc..Hericiumerinaceustabletcontainspolysaccharideandpolypeptide,whichcanbeusedaswellasrawstomachketone.Bilerefluxcanbeindicatedbytheuseofmetoclopramideandmetoclopramidetoincreasegastricperistalsisandreducebilereflux.Cholestyramine,sucralfatecombinedwithbileacid,relievesymptoms.Patientswithirondeficiencyanemiacantakeferroussulfateorirondextrandextran..Three,operationwithseveredysplasiaatpresentthatprecancerouslesionintreatmentofchronicatrophicgastritis,advocatesurgicaltreatmentshouldbeconsidered.prognosisTheprognosisisgenerallygood.Superficialgastritiscanbereversedtonormal,oritcandevelopintoatrophicgastritis.Asmallnumberofatrophicgastritismaydevelopintogastriccancer.Accordingtoreports,therateofcancerationofatrophicgastritisinChinahaschangedbyabout2.5%.