第4章急性胃炎--内科学8版

1、Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege第四篇消化系统疾病第四篇消化系统疾病 第四章第四章 胃炎胃炎 成都医学院第一附属医院消化内科成都医学院第一附属医院消化内科 王静王静Department of GastroenterologyDepartment of GastroenterologyTh

2、e First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege第四章 胃炎 第一节、急性胃炎第一节、急性胃炎（acuteacute gastritis gastritis） Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hosp

3、ital of Chengdu Medical CollegeCollege目的和要求目的和要求1.1. 掌握本病掌握本病临床表现、诊断要点临床表现、诊断要点以以及及防治原则防治原则2.2. 熟悉熟悉本病病因、发病机制本病病因、发病机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege讲授主要内容概述概述

4、常见病因及病理生理机制常见病因及病理生理机制临床表现临床表现诊断诊断治疗治疗预后预后预防预防Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege概述概述急性胃炎急性胃炎也称糜烂性胃炎、出血性胃炎、急性胃粘膜病变也称糜烂性胃炎、出血性胃炎、急性胃粘膜病变临床上急性发病，常表现为上腹部症状临床上急性发病，常表现

5、为上腹部症状内镜检查可见内镜检查可见胃粘膜充血胃粘膜充血、水肿、水肿、出血出血、糜烂糜烂、浅表溃疡、浅表溃疡等一过性病变等一过性病变病理组织学特征病理组织学特征为胃粘膜固有层见到以为胃粘膜固有层见到以中性粒细胞中性粒细胞为主的为主的炎症细胞炎症细胞胃病：胃病：炎性细胞浸润很轻或无，以上皮和微血管的异常改炎性细胞浸润很轻或无，以上皮和微血管的异常改变为主变为主Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First A

6、ffiliated Hospital of Chengdu Medical CollegeCollege分类分类单纯性胃炎单纯性胃炎糜烂出血性胃炎糜烂出血性胃炎腐蚀性胃炎腐蚀性胃炎化脓性胃炎化脓性胃炎Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege常见病因及病理生理机制常见病因及病理生理机制应激应激药物

7、药物酒精酒精创伤和物理因素创伤和物理因素十二指肠十二指肠- -胃反流胃反流胃粘膜血液循环障碍胃粘膜血液循环障碍Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因病因-应激应激 诱因诱因 严重创伤、大手术、大面积烧伤、脑血管意外、严重脏严重创伤、大手术、大面积烧伤、脑血管意外、严重脏器功能衰竭、休克、败

8、血症器功能衰竭、休克、败血症临床表现临床表现 胃粘膜糜烂和出血胃粘膜糜烂和出血机制机制 胃粘膜微循环障碍、缺氧，粘液分泌减少胃粘膜微循环障碍、缺氧，粘液分泌减少 局部前列腺素合成不足，屏障功能损害局部前列腺素合成不足，屏障功能损害 胃酸分泌增加，大量氢离子反渗，损伤血管和黏膜胃酸分泌增加，大量氢离子反渗，损伤血管和黏膜Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital o

9、f Chengdu Medical CollegeCollege病因病因-药物药物非甾体抗炎药非甾体抗炎药（non-steroidal anti-inflammatory drug, non-steroidal anti-inflammatory drug, NSAIDsNSAIDs）最常见，最常见，如如阿司匹林阿司匹林、吲哚美辛吲哚美辛；某些抗生素某些抗生素或抗肿瘤药物或抗肿瘤药物、口服、口服氯化钾氯化钾或或铁剂铁剂非甾体抗炎药非甾体抗炎药 局部作用：局部作用：直接损伤胃粘膜上皮层直接损伤胃粘膜上皮层 全身作用：全身作用：抑制环氧合酶（抑制环氧合酶（COXCOX），抑制前列腺素产生，），抑制

10、前列腺素产生，破坏胃粘膜屏障的完整性破坏胃粘膜屏障的完整性 肠溶剂型肠溶剂型的的NSAIDsNSAIDs可以引起急性胃炎可以引起急性胃炎Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因病因-药物药物Department of GastroenterologyDepartment of Gastroe

11、nterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因病因-药物药物抗肿瘤化疗药物抗肿瘤化疗药物 对肠黏膜产生细胞毒作用，导致严重的黏膜糜烂对肠黏膜产生细胞毒作用，导致严重的黏膜糜烂 合并细菌和病毒感染增加合并细菌和病毒感染增加口服口服氯化钾氯化钾、铁剂、辣椒铁剂、辣椒 直接刺激胃粘膜引起糜烂损伤直接刺激胃粘膜引起糜烂损伤Department of GastroenterologyDepartment o

12、f GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因-酒精酒精 具有亲脂性和溶脂能力具有亲脂性和溶脂能力 高浓度乙醇直接破坏黏膜屏障，引起上皮细胞高浓度乙醇直接破坏黏膜屏障，引起上皮细胞损害和破坏、导致黏膜内出血、糜烂和水肿损害和破坏、导致黏膜内出血、糜烂和水肿 炎症细胞浸润多不明显炎症细胞浸润多不明显Department of GastroenterologyDepartment o

13、f GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因-创伤和物理因素创伤和物理因素放置鼻胃管放置鼻胃管剧烈恶心或干呕剧烈恶心或干呕胃内异物胃内异物食管裂孔疝食管裂孔疝胃镜下各种止血技术胃镜下各种止血技术息肉摘除息肉摘除大剂量放射线照射大剂量放射线照射Department of GastroenterologyDepartment of GastroenterologyThe First

14、 Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因-十二指肠十二指肠- -胃反流胃反流原因：原因： 上消化道动力异常、幽门括约肌功能不全、胃毕上消化道动力异常、幽门括约肌功能不全、胃毕氏术后、十二指肠远端梗阻氏术后、十二指肠远端梗阻临床表现临床表现: : 十二指肠内容物、胆汁、肠液和胰液反流入胃十二指肠内容物、胆汁、肠液和胰液反流入胃腔，其中胆汁酸和溶血卵磷脂可以损伤胃粘膜腔，其中胆汁酸和溶血卵磷脂可以损伤胃粘膜上皮细胞，引起糜烂和出血

15、上皮细胞，引起糜烂和出血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因-胃粘膜血液循环障碍胃粘膜血液循环障碍门脉高压性胃病门脉高压性胃病 胃底静脉曲张，不能及时清除代谢产物，胃黏膜常胃底静脉曲张，不能及时清除代谢产物，胃黏膜常有渗血及糜烂有渗血及糜烂胃黏膜血管炎胃黏膜血管炎 胃动脉栓塞后的局部区域

16、、罕见疾病伴随胃粘膜血管胃动脉栓塞后的局部区域、罕见疾病伴随胃粘膜血管炎，胃粘膜缺血，从而导致糜烂或出血炎，胃粘膜缺血，从而导致糜烂或出血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因幽门螺杆菌感染幽门螺杆菌感染HpHp的作用机制的作用机制粘附作用：粘附作用：HpHp具有黏附素能紧贴上皮细胞，使细

17、胞绒毛断裂，细菌被具有黏附素能紧贴上皮细胞，使细胞绒毛断裂，细菌被绒毛覆盖，不易去除绒毛覆盖，不易去除蛋白酶的作用：蛋白酶的作用：HpHp可产生蛋白酶分解蛋白质，并消化上皮细胞膜，破可产生蛋白酶分解蛋白质，并消化上皮细胞膜，破坏黏液屏障结构坏黏液屏障结构尿素酶作用：尿素酶作用：HpHp具有很强的尿素酶活性，将尿素分解为具有很强的尿素酶活性，将尿素分解为NHNH3 3，既能保护，既能保护细菌的生长环境，又能损伤上皮细胞细菌的生长环境，又能损伤上皮细胞毒素作用：毒素作用：HpHp具有具有细胞毒素相关基因蛋白细胞毒素相关基因蛋白(cag(cag A) A)，能引起强烈的炎症，能引起强烈的炎症反应反应

18、, ,空泡毒素空泡毒素A A（VacVac A A）细胞空泡变性细胞空泡变性免疫反应免疫反应: : HpHp菌体细胞还可作为抗原产生免疫反应菌体细胞还可作为抗原产生免疫反应Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege临床表现临床表现常见症状：常见症状：上腹痛、胀满、恶心、呕吐和食欲不振上腹痛、胀满、

19、恶心、呕吐和食欲不振重症重症呕血、黑粪、脱水、酸中毒或休克呕血、黑粪、脱水、酸中毒或休克轻者轻者无症状无症状体征：体征：上腹部或脐周压痛，肠鸣音亢进上腹部或脐周压痛，肠鸣音亢进门静脉高压门静脉高压或或慢性肝病慢性肝病的症状和体征的症状和体征Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege诊断诊断诊断：诊

20、断：依靠依靠病史病史及及临床表现，内镜检查临床表现，内镜检查确诊确诊内镜下表现：内镜下表现：弥漫分布的多发性糜烂、出血弥漫分布的多发性糜烂、出血灶和浅表溃疡形成。灶和浅表溃疡形成。强调内镜宜在强调内镜宜在24-4824-48小时内进行小时内进行Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege黏膜红斑及出

21、血黏膜红斑及出血：红斑位于胃底，点片状，大小不一，并可见出血灶红斑位于胃底，点片状，大小不一，并可见出血灶Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege黏膜出血黏膜出血：胃底部黏膜广泛出血，点状或小片状，并密集融合成片，色鲜红胃底部黏膜广泛出血，点状或小片状，并密集融合成片，色鲜红Department

22、 of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege黏膜出血黏膜出血：胃窦及胃体交界处黏膜广泛出血，点片状，色红胃窦及胃体交界处黏膜广泛出血，点片状，色红Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospit

23、al of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege黏膜糜烂、出血黏膜糜烂、出血：胃底黏膜广泛、糜烂出血，渗出的血液附于黏膜表面，色暗红胃底黏膜广泛、糜烂出血，渗出的血液附于黏膜表面，色暗红Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chen

24、gdu Medical CollegeCollege鉴别诊断鉴别诊断急性胆囊炎急性胆囊炎急性胰腺炎急性胰腺炎早期阑尾炎早期阑尾炎Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗 病因治疗病因治疗针对原发病和病因采取防治措施去除病因，停止一切对胃针对原发病和病因采取防治措施去除病因，停止一切对胃有刺

25、激的饮食和药物有刺激的饮食和药物 对处于严重应激状态的疾病，除治疗原发病外，应常规予对处于严重应激状态的疾病，除治疗原发病外，应常规予抑酸或粘膜保护药物抑酸或粘膜保护药物 对于服用对于服用NSAIDNSAID的患者视情况予的患者视情况予H H2 2RA/PPIRA/PPI或米索前列醇预防或米索前列醇预防暂时禁食或流质饮食，多饮水暂时禁食或流质饮食，多饮水Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Aff

26、iliated Hospital of Chengdu Medical CollegeCollege治 疗 对症处理对症处理解痉解痉东莨菪碱、普鲁本辛、东莨菪碱、普鲁本辛、654-2654-2止吐止吐甲氧氯普胺甲氧氯普胺10mg im10mg im或多潘立酮或多潘立酮10mg tid10mg tid抑酸抑酸H H2 2RARA或或PPIPPI纠正水、电解质失衡，呕吐、腹泻严重者应输液纠正水、电解质失衡，呕吐、腹泻严重者应输液存在上消化道大出血者按上消化道出血治疗原则采取存在上消化道大出血者按上消化道出血治疗原则采取综合治疗综合治疗Department of GastroenterologyDe

27、partment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege预后预后多数胃粘膜糜烂和出血可自行愈合及止血多数胃粘膜糜烂和出血可自行愈合及止血少数发展为溃疡，并发症增加少数发展为溃疡，并发症增加通常对药物反应良好通常对药物反应良好Department of GastroenterologyDepartment of GastroenterologyThe First Affili

28、ated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege预预 防防停用不必要的停用不必要的NSAIDsNSAIDs治疗治疗应激状态、需要长期服用阿司匹林或氯吡格雷等，可预防应激状态、需要长期服用阿司匹林或氯吡格雷等，可预防性给予性给予H H2 2RARA骨关节病患者，可选择性骨关节病患者，可选择性COX-COX-2 2抑制剂（抑制剂（塞来昔布塞来昔布、美洛昔美洛昔康康），减少对），减少对COX-COX-1 1的抑制的抑制倡导文明的饮食习惯，避免酗酒倡导文明的饮

29、食习惯，避免酗酒门静脉高压性胃病可给予门静脉高压性胃病可给予PPIPPI，严重者考虑介入治疗，严重者考虑介入治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege第二节第二节 慢性胃炎慢性胃炎目的和要求目的和要求1. 1. 掌握本病掌握本病临床表现、诊断要点临床表现、诊断要点以及以及防治原则防治原则2.

30、2. 熟悉熟悉本病病因、发病机制本病病因、发病机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege概概 述述胃粘膜色泽不均、颗粒状增殖及黏膜皱襞异常胃粘膜色泽不均、颗粒状增殖及黏膜皱襞异常组织学以显著炎症细胞浸润、上皮增殖异常、胃组织学以显著炎症细胞浸润、上皮增殖异常、胃腺萎缩及瘢痕形成腺萎缩及瘢痕形成

31、病变轻者不需要治疗，当病变轻者不需要治疗，当上皮增殖异常上皮增殖异常、胃腺萎胃腺萎缩缩时应积极治疗时应积极治疗幽门螺杆菌（幽门螺杆菌（Hp)Hp)感染感染是最常见原因是最常见原因Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制 HpHp感染感染 定居于定居于黏液层黏液层与与胃

32、窦黏膜上皮细胞胃窦黏膜上皮细胞表面，一般不表面，一般不侵入胃腺和固有层侵入胃腺和固有层 避免避免胃酸胃酸的杀菌作用和的杀菌作用和免疫机能免疫机能的清除的清除 产生尿素酶，分解尿素，产生氨，改变局部微环产生尿素酶，分解尿素，产生氨，改变局部微环境境Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病

33、机制病因及发病机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege 病因和发病机制病因和发病机制-HpHp感染感染 HpHp的作用机制的作用机制粘附作用：粘附作用：HpHp具有黏附素能紧贴上皮具有黏附素能紧贴上皮细胞，使细胞绒毛断裂，细菌被绒细胞，使细胞绒毛断裂，细菌被绒毛覆盖，不易去除毛覆盖，不易去除

34、蛋白酶的作用：蛋白酶的作用：HpHp可产生蛋白酶分解可产生蛋白酶分解蛋白质，并消化上皮细胞膜，破坏蛋白质，并消化上皮细胞膜，破坏黏液屏障结构黏液屏障结构Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和发病机制病因和发病机制-HpHp感染感染尿素酶作用：尿素酶作用：HpHp具有很强的尿素酶活性，将具

35、有很强的尿素酶活性，将尿素分解为尿素分解为NHNH3 3，既能保护细菌的生长环，既能保护细菌的生长环境，又能损伤上皮细胞境，又能损伤上皮细胞毒素作用：毒素作用：HpHp具有具有细胞毒素相关基因蛋白细胞毒素相关基因蛋白(cag(cag A) A)，能引起强烈的炎症反应，能引起强烈的炎症反应, ,空泡毒空泡毒素素A A（VacVac A A）细胞空泡变性细胞空泡变性免疫反应免疫反应: : HpHp菌体细胞还可作为抗原产生免菌体细胞还可作为抗原产生免疫反应疫反应Department of GastroenterologyDepartment of GastroenterologyThe First

36、Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制- HpHp感染感染疾病发展取决于疾病发展取决于毒株毒株毒力毒力宿主个体差异宿主个体差异胃内微生态环境胃内微生态环境Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affilia

37、ted Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制-十二指肠十二指肠- -胃反流胃反流“漏屋顶漏屋顶”假说假说中国古话：中国古话：“屋漏更逢夜雨屋漏更逢夜雨”Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制

38、- 十二指肠十二指肠- -胃反流胃反流 胃肠慢性炎症、消化吸收不良及动力障碍所致长胃肠慢性炎症、消化吸收不良及动力障碍所致长 期反流，可导致胃粘膜慢性炎症期反流，可导致胃粘膜慢性炎症Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制-自身免疫自身免疫壁细胞抗体壁细胞抗体（PCA

39、)PCA) 导致壁细胞总数减少，胃酸分泌减少导致壁细胞总数减少，胃酸分泌减少内因子抗体内因子抗体（IFA)IFA) 导致内因子不能与维生素导致内因子不能与维生素B12B12形成复合形成复合出现巨幼细胞贫血出现巨幼细胞贫血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制-年龄因

40、素和胃黏膜营养年龄因素和胃黏膜营养因子缺乏因子缺乏胃黏膜退行性改变胃黏膜退行性改变 老年人胃黏膜小血管扭曲，小动脉玻璃样变老年人胃黏膜小血管扭曲，小动脉玻璃样变性，管腔狭窄性，管腔狭窄 胃黏膜营养不良、分泌功能下降和屏障功能胃黏膜营养不良、分泌功能下降和屏障功能降低降低胃黏膜修复再生功能降低胃黏膜修复再生功能降低 长期消化吸收不良、食物单一、营养缺乏，长期消化吸收不良、食物单一、营养缺乏，炎症慢性化，上皮异常增生及胃腺萎缩炎症慢性化，上皮异常增生及胃腺萎缩Department of GastroenterologyDepartment of GastroenterologyThe First

41、Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理慢性非萎缩性胃炎慢性非萎缩性胃炎（chronic non-atrophic chronic non-atrophic gastritisgastritis，CNAGCNAG） 黏膜红黄相间，或黏膜皱襞肿胀增粗黏膜红黄相间，或黏膜皱襞肿胀增粗慢性萎缩性胃炎慢性萎缩性胃炎（chronic atrophic gastritischronic atrophic gastritis，CA

42、GCAG） 黏膜色泽变淡，皱襞变细而平坦，粘液减少，黏膜色泽变淡，皱襞变细而平坦，粘液减少， 黏膜变黏膜变薄，有时可透见血管薄，有时可透见血管 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理CNAGCNAG黏膜红斑：黏膜红斑：红斑呈片状，较密集地分布于胃窦四壁红斑呈片状，较密集地分布于

43、胃窦四壁Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理CAGCAG：轻度并黏膜糜烂轻度并黏膜糜烂Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Ch

44、engdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理CAGCAG：黏膜变薄，血管透见黏膜变薄，血管透见Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理CAGCAG黏膜粗糙

45、伴点状出血：黏膜粗糙伴点状出血：胃窦部黏膜粗糙，局部以白相为胃窦部黏膜粗糙，局部以白相为主，伴散在出血主，伴散在出血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理 慢性胃炎分类慢性胃炎分类胃窦炎胃窦炎 多由多由HpHp感染引起感染引起胃体炎胃体炎 多与自身免疫有关，病变主要累及胃体和胃

46、底多与自身免疫有关，病变主要累及胃体和胃底全胃炎全胃炎 可由可由HpHp感染扩展而来感染扩展而来Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理 胃镜活检部位胃镜活检部位Department of GastroenterologyDepartment of Gastroenterolog

47、yThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理-炎症 炎症活动性分度炎症活动性分度 轻度轻度：粘膜固有层有少数：粘膜固有层有少数中性粒细中性粒细胞浸润胞浸润 中度中度：中性粒细胞较多存在于粘膜层，可见于：中性粒细胞较多存在于粘膜层，可见于上皮细胞、小凹细胞或腺管上皮内上皮细胞、小凹细胞或腺管上皮内 重度重度：中性粒细胞较密集或除中度所见外还可：中性粒细胞较密集或除中度所见外还可见小凹脓肿见小凹脓肿 D

48、epartment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理-炎症 慢性炎症分度慢性炎症分度 轻度轻度：慢性炎症细胞较少并局限于粘膜表层，：慢性炎症细胞较少并局限于粘膜表层， 不超过粘膜层的不超过粘膜层的1/31/3 中度中度：慢性炎症细胞较密集，不超过粘膜层的：慢性炎症细胞较密集，不超过粘膜层的2/

49、32/3 重度重度：慢性炎症细胞密集，占据：慢性炎症细胞密集，占据粘膜全层粘膜全层 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理-化生化生 化生化生 胃黏膜胃黏膜表层上皮表层上皮和和腺上皮腺上皮被被杯状细胞杯状细胞和和幽门腺细胞幽门腺细胞取代取代 肠上皮化生肠上皮化生 杯状细胞的肠腺

50、取代了胃固有腺杯状细胞的肠腺取代了胃固有腺 假幽门腺化生假幽门腺化生 泌酸腺的颈黏液细胞增生，形成幽门腺样腺体泌酸腺的颈黏液细胞增生，形成幽门腺样腺体Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理-萎缩萎缩胃粘膜萎缩胃粘膜萎缩主要表现主要表现 胃粘膜固有层腺体（胃粘膜固有层腺体（幽门腺

51、或泌酸腺幽门腺或泌酸腺）数量减少甚至消）数量减少甚至消失，伴纤维组织增生、粘膜肌增厚，严重者胃粘膜变薄失，伴纤维组织增生、粘膜肌增厚，严重者胃粘膜变薄萎缩组织学有两种类型萎缩组织学有两种类型 化生性萎缩化生性萎缩 固有腺体被固有腺体被肠化肠化或或假幽门腺体假幽门腺体替代替代 非化生性萎缩非化生性萎缩 胃粘膜固有腺体被胃粘膜固有腺体被纤维组织纤维组织或纤或纤维肌性组织维肌性组织或炎性细胞浸润引起固有腺体数量或炎性细胞浸润引起固有腺体数量减少减少Department of GastroenterologyDepartment of GastroenterologyThe First Affilia

52、ted Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理胃镜及组织学病理-异型增生异型增生不典型增生不典型增生(dysplasia)(dysplasia) 上皮内瘤变上皮内瘤变 细胞在增生的过程中过度增生和分化缺失，增细胞在增生的过程中过度增生和分化缺失，增生的上皮细胞拥挤、有分层现象，核增大失去生的上皮细胞拥挤、有分层现象，核增大失去极性，有丝分裂象增多，腺体结构紊乱。极性，有丝分裂象增多，腺体结构紊乱。 分为分为轻轻、中中、重重三度，轻者可逆

53、转为正常，重三度，轻者可逆转为正常，重者不易于高分化腺癌区别。者不易于高分化腺癌区别。中度以上中度以上的不典型的不典型增生被认为可能是癌前病变增生被认为可能是癌前病变 化生化生、萎缩萎缩及及异常增生异常增生被视为胃癌前状态被视为胃癌前状态Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege临床表现临床表现

54、多数患者多数患者无症状无症状或症状很轻或症状很轻 部分病人表现为部分病人表现为消化不良消化不良的症状：中上腹不适、的症状：中上腹不适、饱胀、钝痛、烧灼痛、食欲不振、嗳气、泛酸、饱胀、钝痛、烧灼痛、食欲不振、嗳气、泛酸、恶心等恶心等 恶性贫血恶性贫血者有全身衰弱、疲软、明显厌食、体重者有全身衰弱、疲软、明显厌食、体重减轻、贫血等减轻、贫血等Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated

55、Hospital of Chengdu Medical CollegeCollege诊诊 断断胃镜胃镜及及组织学检查组织学检查是慢性胃炎诊断关键是慢性胃炎诊断关键HpHp检测检测非侵入性非侵入性1313C-C-或或1414C-C-尿素呼气试验、血清尿素呼气试验、血清HpHp抗体、粪便查抗体、粪便查HpHp等等侵入性侵入性快速尿素酶试验、嗜银染色或苏木紫快速尿素酶试验、嗜银染色或苏木紫- -曙红染色、直接涂曙红染色、直接涂片染色、微需氧培养等片染色、微需氧培养等Department of GastroenterologyDepartment of GastroenterologyThe Firs

56、t Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege诊诊 断断血清抗壁细胞抗体、内因子抗体和维生素血清抗壁细胞抗体、内因子抗体和维生素B B1212水平水平测定测定空腹血清维生素空腹血清维生素B B1212浓度为浓度为300-900ng/L300-900ng/LDepartment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital o

57、f Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗不需要药物治疗不需要药物治疗 非活动性、轻度慢性浅表性胃炎非活动性、轻度慢性浅表性胃炎需要药物治疗需要药物治疗慢性胃炎波及黏膜全层或呈活动性慢性胃炎波及黏膜全层或呈活动性出现癌前状态（肠上皮化生、假幽门腺化生、萎缩及不典出现癌前状态（肠上皮化生、假幽门腺化生、萎缩及不典型增生）型增生）Department of GastroenterologyDepartment of GastroenterologyThe First Aff

58、iliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗-对因治疗 HpHp相关性胃炎相关性胃炎方案方案 1 1种种PPI+1PPI+1种铋剂种铋剂+2+2种抗生素种抗生素疗程疗程 7-147-14天天Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affili

59、ated Hospital of Chengdu Medical CollegeCollege治 疗-对因治疗 十二指肠十二指肠- -胃反流胃反流助消化助消化改善胃动力改善胃动力Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗-对因治疗 自自 身身 免免 疫疫糖皮质激素糖皮质激素Departmen

60、t of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治治 疗疗-对因治疗对因治疗 胃黏膜营养因子缺乏胃黏膜营养因子缺乏补充补充复合维生素复合维生素改善改善胃肠营养胃肠营养Department of GastroenterologyDepartment of GastroenterologyThe First Affiliat