内科学胃炎(英文)

Gastritis

1DefinitionGastritisAwidevarietyofinflammatoryorhemorrhagicconditionsofgastricmucosa:DamageInflammationRegenerationGastropathyEpithelialcelldamageandregenerationwithoutassociatedinflammation

2AnatomicalsiteANTRUM胃窦CARDIA贲门BODY胃体MUCOUSSECRETINGENDOCRINESPECIALISEDSECRETORYPARIETAL–ACIDCHIEF-PEPSINOGEN

ENDOCRINE：Dcell：HISTAMINEMastocyte：SOMATOSTATINMUCOUSSECRETINGENDOCRINE：

GASTRIN,5HydroxylTryptamine3GrosshistologicGastritisismostlyahistologicaltermthatneedsbiopsytobeconfirmed4Classification

AcuteGastritis

ChronicgastritisAcutereferringtoshortterminflammationAcutereferringtoneutrophilicinfiltrate-Chronicreferringtolongstandingforms-Chronicreferringtomononuclearcellinfiltrateespeciallylymphocyteandmacrophages5

AcuteGastritisDeveloping

shortly

exposuretovariousinjurioussubstancesorfollowingdepressioninmucosalbloodflow6AcuteGastritisErosive&HemorrhagicgastritisHelicobacterpylori-inducedgastritisInfectiousgastritis(excludingH.pylori)7EtiologyandPathogenesisStress

Shock;

Sepsis;

Burn;

CNSTraumaorSurgery

Renal,HepaticorRespiratoryFailureChemicalinjuryNSAIDs

AlcoholBacteriaandToxin(Helicobacterpylori)8Mucosaischemia;thromboxaneA2,leukotrieneC4Inhibitionofepithelialrenewal;Impairmentofgastricmucosabarrier;Hydrogenionback-diffusion;FreeradicalsStressRelatedGastricMucosaDamage9

NSAIDsandGastritisInhibitingsynthesisofprostaglandinsbyinhibitingcyclooxygenase(COX,环氧合酶)Chemicalinjury10

AlcoholandGastritis

Alcoholislipid-solubleHighconcentrationofethanoltransversesgastricmucosaandresultsinmucosadamageChemicalinjury11

ClinicalManifestationsAcuteErosive&HemorrhagicGastritisUpperGIBleeding

Hematemesis;

Melena;

OccultBloodinStool

12

ClinicalManifestationsEpigastricPainordiscomfortAnorexiaNauseaandVomiting13DefiniteDiagnosis:EmergencyEndoscopy14Mucosalcongestion,oedema,inflammation&ulcerationACUTEGASTRITIS-MORPHOLOGY15TwoSpecialTermsinAcuteErosive&HemorrhagicGastritis

CushingUlcer

ErosionsandulcersassociatedwithCNStraumaorsurgeryCurlingUlcer

Erosionsandulcersassociatedwithburn16RemoveoffendingagentsTreatpredisposingconditionsSymptomatictreatmentProtectgastricmucosa:SucralfateTreatment17

Inhibitorneutralizegastricacid:

Antiacids

H2-receptorantagonists(H2-RAs)

Cimetidine,Ranitidine,Famotidine

ProtonpumpInhibitors(PPIs)

Omaprazole,Lansoprazole,Pantoprazole,Rabeprazole,EsoprazoleTreatment18AvoidoffendingagentsProphylacticuseofacid-inhibitingormucosa-protectingdrugs:

Sucralfate;

H2-receptorantagonists

PPIsPrevention19

ChronicGastritis20ChronicGastritisChronicreferringtolongstandingformsChronicreferringtomononuclearcellinfiltrateespeciallylymphocyteandmacrophagesGastritisisdefinedasmicroscopicinflammationofthestomachandrepresentsahistologicalnotaclinicalentity,asthemajorityofpersonswithgastricinflammationarecompletelyasymptomatic.21

1.Whitehead(1972)Superficial

ChronicGastritis

Atrophic

Classification22

2.Strickland(1973)TypeAAtrophicGastritisTypeB

2324ClassificationofCAGbyStricklandFeaturesTypeATypeBMorphologyantrumnormalatrophycorpusdiffusemultifocalSerumgastrinGastricacidsecretionanacidityhypoacidityGastricautoantibodies90%10%Frequencyin90%10%perniciousanemiaproposedetiologicalautoimmunitymucosafactorsgeneticcomponentirritants253.SydneySystem(1990)

UpdatedSydneySystem(1996)ThemostwidelyusedmethodforclassificationofgastritisClassifingchronicgastritisbasedontopography,morphology,andetiology

2627281.重庆共识（1982）

SuperficialAtrophic(Hypertrophic)

Location:antrum,corpusorpan-;

Severity:mild,moderate,severe;

Activity:active,quiescent;

Metaplasia:intestinal,pseudopyloric2.井冈山共识（2000）3.上海共识（2006）(SydneySystem）4.上海共识（2012）Nationalconsensus29EtiologyandPathogenesis30

1.HelicobacterpyloriInfection:

(Koch’spostulates)HighprevalenceofHpinfectioninpatientswithchronicactivegastritis(80-95%).Hpinfectionisassociatedwithgastricmucosalinflammation.

Samedistribution

InflammationsubsidesaftereradicationofHpStudiesinvolunteerandanimalmodels.313233AntigenicMimicry

GastricEpithelium,Gcells,CanaliculiofParietalCells,H+,K+-ATPaseAntibodyLipopolysaccharideHeatShockProtein342.ImmunologicalFactorsParietalcellantibody(PCA)andintrinsicfactorantibody(IFA)arein90%ofpatientswithtypeAatrophicgastritisandperniciousanemia.Perniciousanemiaisalsoassociatedwithotherautoimmunediseases:

Hashimoto’sthyroiditis;

Diabetesmellitus;

Vitiligo白癫风353.Duodenal-GastricReflux(a)Dysfunctionofpyloricsphincter(b)AfterPartialGastrectomy36

Bile

Pancreatic

Enzymes

Lecithin

卵磷脂

Lysolecithin

溶血卵磷脂

DamageofGastricMucosalBarrierMechanismsofGastricMucosalDamagebyDuodenalContents37Asymptomaticinmajorityofpatients;

Somehavedyspepticsymptoms:

Epigastricpainordiscomfort

Belching

Regurgitation

Lossofappetite

Nauseaandvomiting

Somemaydevelopsymptomaticcomplication:

Anemia;Pepticulcer;

Gastricpolyp;GastriccarcinomaClinicalManifestation38Non-AtrophicGastritis:

Infiltrationofplasmacell,lymphocytesandneutrophilsinlaminapropria.Surfacecellsdamage

HistologyofChronicGastritis39AtrophicGastritis:Inflammatorycellsinfiltration

AtrophyofgastricglandsMetaplasia:

IntestinalMetaplasia

PseudopyloricMetaplasiaDysplasiaHistologyofChronicGastritis404142TwoTypesofMetaplasiainGastricMucosaLinedbyintestinal-typeabsorptivecells,gobletcellsandPenethcells—IntestinalMetaplasiaLinedbymucus-secretingcellssimilartothoseinantralmucosa—

PseudopyloriMetaplasia43GastricPrecancerousChangesPrecancerouslesion(Dysplasia)PrecancerousConditionsAtrophicGastritisGastricPolypGastricUlcerGastricStumpMenetrier’sDiseaseWHO,19784445LaboratoryExaminationsDetectionofH.pyloriinfectionGastricSecretoryTestLowacidornoacidintypeAgastritisSerologyTestsGastrinA:IFA(intrinsicfactorAb)A:PCA(parietalcellAb)VitaminB12level(300-900ng/L)GastroscopyHistology46

Non-AtrophicgastritisEdema;Hyperemia;Exudate;ErosionThedefinitivediagnosisismadeonlybygastroscopyandbiopsyofgastricmucosa47AtrophicgastritisVissiblebloodvessels;Thinningofgastricmucosa48RapidureasetestHistologyCultureDirectsmearPCR13C-BreathtestDetectionofH.pyloriInfection49H&EStainCresylvioletstain

Warthin-StarryStainAcridineorangestain

5051Diagnosis

NoanysymptominmostofpatientsSymptomsarenon-specificDefinitivediagnosisismadeonlybyendoscopyandbiopsy52Removeoffendingagents;Symptomatictreatment;EradicationofHp;PreventionofDuodenal-gastricreflux;Supplementwithanti-oxidantsforCAG;Follow-upforCAGwithhighriskofgastriccancerTreatment53

PreventionofDuodenal-gastricReflux

Prokinetic:

–Metoclopramide胃复安;

–Domperidone多潘立酮;

–Mosapride莫沙比利

Bile-bindingagents:

–Cholestyramine

SupplementwithAnti-oxidants:

VitaminC

VitaminE

-carotene,

Selenium硒54RoleofAnti-oxidantsinPreventionofGastricCancer

Anti-oxidants

Nitrate

NitriteNitrosoCompoundsInflammationFreeRadicalsDamageofepitheliumDNAmutation(–)(–)55

Follow-up

Atrophicgastritisisoneofprecancerousconditions,theannualriskforgastriccancerisabout0.5%.

Patientswithsevereatrophicgastritisordysplasia

shouldbecloselyfollowedupbyendoscopy.56SpecialformsofgastritisChemical(reactive)gastropathy

(NSAIDandbilereflux)Otherinfectiousgastritis(excludingH.pylori)Menetrier’sDisease57SpecialformsofgastritisChemical(reactive)gastropathy

(NSAIDandbilereflux)EpithelialcelldamageandregenerationWithoutassociatedinflammation58SpecialformsofgastritisOtherinfectiousgastritis(excludingH.pylori)BacteriaotherthanH.pylori

Phlegmonousgastritis(蜂窝织性胃炎）Viruses:CytomegalovirusFungi：Parasites：

Anisakiasis（异尖线虫病）59

Menetrier’sDisease

（Characterizedbylargemucosafoldsinstomach）HistologyHyperplasiaofpitsmucuscellsAcidsecretionNormalorlowLossofproteinYesTherapyHighproteindietEradicationofHpGastrectomy6061SummuryDefinition:

Awidevarietyofinflammatoryorhemorrhagicconditionsofgastricmucosa.Classification:AcuteGastritis