急性胃炎内科学培训 医学ppt课件

Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第四篇消化系统疾病第四篇消化系统疾病 胃炎 第四篇消化系统疾病 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第四章 胃炎 第一节、急性胃炎（acute gastritis）第四章 胃炎 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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、发病机制目的和要求1.掌握本病临床表现、诊断要点以及防治原则Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College讲授主要内容概述常见病因及病理生理机制临床表现诊断治疗预后预防讲授主要内容概述Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College概述概述急性胃炎也称糜烂性胃炎、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内镜检查可见胃粘膜充血、水肿、出血、糜烂、浅表溃疡等一过性病变病理组织学特征为胃粘膜固有层见到以中性粒细胞为主的炎症细胞胃病：炎性细胞浸润很轻或无，以上皮和微血管的异常改变为主概述急性胃炎也称糜烂性胃炎、出血性胃炎、急性胃粘膜病变Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College分类分类单纯性胃炎糜烂出血性胃炎腐蚀性胃炎化脓性胃炎分类单纯性胃炎Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College常见病因及病理生理机制常见病因及病理生理机制应激药物酒精创伤和物理因素十二指肠-胃反流胃粘膜血液循环障碍常见病因及病理生理机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因病因-应激应激 诱因 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、败血症临床表现 胃粘膜糜烂和出血机制 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 胃酸分泌增加，大量氢离子反渗，损伤血管和黏膜病因-应激 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因病因-药物药物非甾体抗炎药（non-steroidal anti-inflammatory drug,NSAIDs）最常见，如阿司匹林、吲哚美辛；某些抗生素或抗肿瘤药物、口服氯化钾或铁剂非甾体抗炎药 局部作用：直接损伤胃粘膜上皮层 全身作用：抑制环氧合酶（COX），抑制前列腺素产生，破坏胃粘膜屏障的完整性 肠溶剂型的NSAIDs可以引起急性胃炎病因-药物非甾体抗炎药（non-steroidal anDepartment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因病因-药物药物病因-药物Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因病因-药物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 合并细菌和病毒感染增加口服氯化钾、铁剂、辣椒 直接刺激胃粘膜引起糜烂损伤病因-药物抗肿瘤化疗药物Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因-酒精酒精 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病因-酒精 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因-创伤和物理因素创伤和物理因素放置鼻胃管剧烈恶心或干呕胃内异物食管裂孔疝胃镜下各种止血技术息肉摘除大剂量放射线照射病因-创伤和物理因素放置鼻胃管Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因-十二指肠十二指肠-胃反流胃反流原因：上消化道动力异常、幽门括约肌功能不全、胃毕氏术后、十二指肠远端梗阻临床表现: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上皮细胞，引起糜烂和出血病因-十二指肠-胃反流原因：Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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 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胃黏膜血管炎 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病因-胃粘膜血液循环障碍门脉高压性胃病Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因幽门螺杆菌感染幽门螺杆菌感染Hp的作用机制粘附作用：Hp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，不易去除蛋白酶的作用：Hp可产生蛋白酶分解蛋白质，并消化上皮细胞膜，破坏黏液屏障结构尿素酶作用：Hp具有很强的尿素酶活性，将尿素分解为NH3，既能保护细菌的生长环境，又能损伤上皮细胞毒素作用：Hp具有细胞毒素相关基因蛋白(cag A)，能引起强烈的炎症反应,空泡毒素A（Vac A）细胞空泡变性免疫反应:Hp菌体细胞还可作为抗原产生免疫反应病因幽门螺杆菌感染Hp的作用机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College临床表现临床表现常见症状：上腹痛、胀满、恶心、呕吐和食欲不振重症呕血、黑粪、脱水、酸中毒或休克轻者无症状体征：上腹部或脐周压痛，肠鸣音亢进门静脉高压或慢性肝病的症状和体征临床表现常见症状：Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College诊断诊断诊断：依靠病史及临床表现，内镜检查确诊内镜下表现：弥漫分布的多发性糜烂、出血灶和浅表溃疡形成。强调内镜宜在24-48小时内进行诊断诊断：依靠病史及临床表现，内镜检查确诊Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College黏膜红斑及出血黏膜红斑及出血：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Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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，Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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，色红黏膜出血：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 Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College鉴别诊断鉴别诊断急性胆囊炎急性胰腺炎早期阑尾炎鉴别诊断急性胆囊炎Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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，应常规予抑酸或粘膜保护药物 对于服用NSAID的患者视情况予H2RA/PPI或米索前列醇预防暂时禁食或流质饮食，多饮水治 疗 病因治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治 疗 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综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合治疗治 疗 对症处理Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College预后预后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，并发症增加通常对药物反应良好预后多数胃粘膜糜烂和出血可自行愈合及止血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College预预 防防停用不必要的NSAIDs治疗应激状态、需要长期服用阿司匹林或氯吡格雷等，可预防性给予H2RA骨关节病患者，可选择性COX-2抑制剂（塞来昔布、美洛昔康），减少对COX-1的抑制倡导文明的饮食习惯，避免酗酒门静脉高压性胃病可给予PPI，严重者考虑介入治疗预 防停用不必要的NSAIDs治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第二节第二节 慢性胃炎慢性胃炎目的和要求1.掌握本病临床表现、诊断要点以及防治原则2.熟悉本病病因、发病机制第二节 慢性胃炎目的和要求Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College概概 述述胃粘膜色泽不均、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、胃腺萎缩及瘢痕形成病变轻者不需要治疗，当上皮增殖异常、胃腺萎缩时应积极治疗幽门螺杆菌（Hp)感染是最常见原因概 述胃粘膜色泽不均、颗粒状增殖及黏膜皱襞异常Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因及发病机制病因及发病机制 Hp感染 定居于黏液层与胃窦黏膜上皮细胞表面，一般不侵入胃腺和固有层 避免胃酸的杀菌作用和免疫机能的清除 产生尿素酶，分解尿素，产生氨，改变局部微环境病因及发病机制 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因及发病机制病因及发病机制病因及发病机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College 病因和发病机制病因和发病机制-HpHp感染感染 Hp的作用机制粘附作用：Hp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，不易去除蛋白酶的作用：Hp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 病因和发病机制-Hp感染 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因和发病机制病因和发病机制-HpHp感染感染尿素酶作用：Hp具有很强的尿素酶活性，将尿素分解为NH3，既能保护细菌的生长环境，又能损伤上皮细胞毒素作用：Hp具有细胞毒素相关基因蛋白(cag A)，能引起强烈的炎症反应,空泡毒素A（Vac A）细胞空泡变性免疫反应:Hp菌体细胞还可作为抗原产生免疫反应病因和发病机制-Hp感染尿素酶作用：Hp具有很强的尿素酶Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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毒株毒力宿主个体差异胃内微生态环境病因及发病机制-Hp感染疾病发展取决于Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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”病因及发病机制-十二指肠-胃反流“漏屋顶”假说Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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 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病因及发病机制-十二指肠-胃反流Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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（PCA)导致壁细胞总数减少，胃酸分泌减少内因子抗体（IFA)导致内因子不能与维生素B12形成复合出现巨幼细胞贫血病因及发病机制-自身免疫壁细胞抗体（PCA)Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College病因及发病机制病因及发病机制-年龄因素和胃黏膜营养因子年龄因素和胃黏膜营养因子缺乏缺乏胃黏膜退行性改变 老年人胃黏膜小血管扭曲，小动脉玻璃样变性，管腔狭窄 胃黏膜营养不良、分泌功能下降和屏障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，炎症慢性化，上皮异常增生及胃腺萎缩病因及发病机制-年龄因素和胃黏膜营养因子缺乏胃黏膜退行性Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理慢性非萎缩性胃炎（chronic non-atrophic gastritis，CNAG）黏膜红黄相间，或黏膜皱襞肿胀增粗慢性萎缩性胃炎（chronic atrophic gastritis，CAG）黏膜色泽变淡，皱襞变细而平坦，粘液减少，黏膜变薄，有时可透见血管 胃镜及组织学病理慢性非萎缩性胃炎（chronic non-aDepartment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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，较密集地分布于胃窦四壁胃镜及组织学病理CNAG黏膜红斑：红斑呈片状，较密集地分布于Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理CAGCAG：轻度并黏膜糜烂轻度并黏膜糜烂胃镜及组织学病理CAG：轻度并黏膜糜烂Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理CAGCAG：黏膜变薄，血管透见黏膜变薄，血管透见胃镜及组织学病理CAG：黏膜变薄，血管透见Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理CAGCAG黏膜粗糙伴点状出血：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，伴散在出血胃镜及组织学病理CAG黏膜粗糙伴点状出血：胃窦部黏膜粗糙，局Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理 慢性胃炎分类胃窦炎 多由Hp感染引起胃体炎 多与自身免疫有关，病变主要累及胃体和胃底全胃炎 可由Hp感染扩展而来胃镜及组织学病理 慢性胃炎分类Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理 胃镜活检部位胃镜及组织学病理 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理-炎症 炎症活动性分度 轻度：粘膜固有层有少数中性粒细胞浸润 中度：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 重度：中性粒细胞较密集或除中度所见外还可见小凹脓肿 胃镜及组织学病理-炎症 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理-炎症 慢性炎症分度 轻度：慢性炎症细胞较少并局限于粘膜表层，不超过粘膜层的1/3 中度：慢性炎症细胞较密集，不超过粘膜层的2/3 重度：慢性炎症细胞密集，占据粘膜全层 胃镜及组织学病理-炎症 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理-化生化生 化生 胃黏膜表层上皮和腺上皮被杯状细胞和幽门腺细胞取代 肠上皮化生 杯状细胞的肠腺取代了胃固有腺 假幽门腺化生 泌酸腺的颈黏液细胞增生，形成幽门腺样腺体胃镜及组织学病理-化生 化生Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College胃镜及组织学病理-萎缩萎缩胃粘膜萎缩主要表现 胃粘膜固有层腺体（幽门腺或泌酸腺）数量减少甚至消失，伴纤维组织增生、粘膜肌增厚，严重者胃粘膜变薄萎缩组织学有两种类型 化生性萎缩 固有腺体被肠化或假幽门腺体替代 非化生性萎缩 胃粘膜固有腺体被纤维组织或纤维肌性组织或炎性细胞浸润引起固有腺体数量减少胃镜及组织学病理-萎缩胃粘膜萎缩主要表现Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College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(dysplasia)上皮内瘤变 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，核增大失去极性，有丝分裂象增多，腺体结构紊乱。分为轻、中、重三度，轻者可逆转为正常，重者不易于高分化腺癌区别。中度以上的不典型增生被认为可能是癌前病变 化生、萎缩及异常增生被视为胃癌前状态胃镜及组织学病理-异型增生不典型增生(dysplasiaDepartment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College临床表现临床表现 多数患者无症状或症状很轻 部分病人表现为消化不良的症状：中上腹不适、饱胀、钝痛、烧灼痛、食欲不振、嗳气、泛酸、恶心等 恶性贫血者有全身衰弱、疲软、明显厌食、体重减轻、贫血等临床表现 多数患者无症状或症状很轻Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College诊诊 断断胃镜及组织学检查是慢性胃炎诊断关键Hp检测非侵入性13C-或14C-尿素呼气试验、血清Hp抗体、粪便查Hp等侵入性快速尿素酶试验、嗜银染色或苏木紫-曙红染色、直接涂片染色、微需氧培养等诊 断胃镜及组织学检查是慢性胃炎诊断关键Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College诊诊 断断血清抗壁细胞抗体、内因子抗体和维生素B12水平测定空腹血清维生素B12浓度为300-900ng/L诊 断血清抗壁细胞抗体、内因子抗体和维生素B12水平测定Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治 疗不需要药物治疗 非活动性、轻度慢性浅表性胃炎需要药物治疗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、萎缩及不典型增生）治 疗不需要药物治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治 疗-对因治疗 Hp相关性胃炎方案 1种PPI+1种铋剂+2种抗生素疗程 7-14天治 疗-对因治疗 Hp相关性Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治 疗-对因治疗 十二指肠-胃反流助消化改善胃动力治 疗-对因治疗 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治 疗-对因治疗 自 身 免 疫糖皮质激素治 疗-对因治疗 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治治 疗疗-对因治疗对因治疗 胃黏膜营养因子缺乏补充复合维生素改善胃肠营养治 疗-对因治疗 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治治 疗疗-对症治疗 抑制或中和胃酸保护胃黏膜恶性贫血终生注射维生素B12治 疗-对症治疗 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治治 疗疗-癌前状态处理癌前状态处理COX-2抑制剂塞来昔布对胃黏膜重度炎症、肠炎、萎缩及异型增生的逆转有一定益处补充复合维生素和含硒食物药物不能逆转的局灶中、重度不典型增生，没有淋巴结转移时，可行黏膜剥离术，定期随访药物不能逆转的重度不典型增生伴有局部淋巴结肿大，应考虑手术治 疗-癌前状态处理COX-2抑制剂塞来昔布对胃黏膜重度Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治治 疗疗-患者教育患者教育食物应多样化，避免偏食，注意补充多种营养物质不吃霉变食物少吃熏制、腌制、富含硝酸盐和亚硝酸盐的食物，多吃新鲜食品避免过于粗糙、浓烈、辛辣食物及大量长期饮酒、戒烟保持良好的心理状态及充分睡眠治 疗-患者教育食物应多样化，避免偏食，注意补充多种营养Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College治治 疗疗-预后预后慢性非萎缩性胃炎预后良好肠上皮化生通常难以逆转部分患者萎缩可以改善或逆转重度不典型增生者易转变为癌对有胃癌家族史、食物营养单一、常食熏制或腌制食品的患者，需警惕肠上皮化生、萎缩及不典型增生向胃癌的进展治 疗-预后慢性非萎缩性胃炎预后良好Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第三节特殊类型的胃炎或胃病第三节特殊类型的胃炎或胃病 腐蚀性胃炎病因 吞服强酸、强碱、砷、磷、氯化汞等临床表现：吞服后即感口腔、咽喉及胸骨后烧灼感，上腹剧痛，伴恶心、呕吐，其程度与腐蚀剂量、浓度、是否空腹有关。重者可发生胃穿孔，引起急性腹膜炎、休克 幸存者常遗留食管或胃流出道狭窄不同的腐蚀剂在口、唇及咽喉部粘膜引起不同颜色的灼痂硫酸黑色痂 盐酸灰棕色 硝酸深黄色 醋酸或草酸白色 强碱透明性水肿第三节特殊类型的胃炎或胃病 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第三节特殊类型的胃炎或胃病第三节特殊类型的胃炎或胃病 腐蚀性胃炎暂时禁食，胃肠外营养，密切监护早期禁行胃镜强酸-弱碱溶液对抗强碱-弱酸溶液对抗不清楚腐蚀剂-牛奶或蛋清喉头水肿、呼吸困难-气管切开胃穿孔、急性腹膜炎-手术修补瘢痕狭窄、吞咽梗阻-胃镜下扩张、安置支架第三节特殊类型的胃炎或胃病 腐蚀Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第三节特殊类型的胃炎或胃病第三节特殊类型的胃炎或胃病 感染性胃炎诱因 免疫缺陷、大剂量应用糖皮质激素和免疫抑制剂、化疗期间或之后，垂危状态细菌感染 病原菌：葡萄球菌、a-溶血链球菌、大肠杆菌 诱因：胃手术及化疗 临床表现：突发上腹痛、恶心、呕吐、呕吐物呈脓样、含有坏死组织，胃扩张，明显压痛及局部肌紧张、发热、甚至化脓性腹膜炎 内科治疗多无效，需紧急手术第三节特殊类型的胃炎或胃病 感染性胃Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第三节特殊类型的胃炎或胃病第三节特殊类型的胃炎或胃病 克隆恩病 多见于胃窦，常与近端十二指肠克隆恩病共存第三节特殊类型的胃炎或胃病 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第三节特殊类型的胃炎或胃病第三节特殊类型的胃炎或胃病 嗜酸性胃炎胃壁炎症以嗜酸性粒细胞浸润为主，不伴有肉芽肿或血管炎性病变，以其中一层为主病变仅累及肌层或浆膜层，胃黏膜活检不易成功可能与过敏原与胃肠组织接触后在胃肠壁内发生抗原抗体反应，释放组胺类血管活性物质临床表现上腹痛、恶心、呕吐、抑酸剂难以缓解腹痛、常伴有腹泻，外周血嗜酸性粒细胞增高本病常为自限性，有些病例可持续存在或复发治疗可用糖皮质激素第三节特殊类型的胃炎或胃病 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College第三节特殊类型的胃炎或胃病第三节特殊类型的胃炎或胃病 Menetrier（曼内特尔）病表层和腺体的黏液细胞过度增生，使胃小凹延长扭曲，在深处有囊样扩张伴有壁细胞和主细胞的减少胃镜下见胃体皱襞粗大、肥厚、扭曲呈脑回状，胃窦黏膜多正常常引起低蛋白血症多见于男性，病因不明，无特效治疗第三节特殊类型的胃炎或胃病 MenetDepartment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical CollegeThe First Affiliated Hospital of Chengdu Medical College思考题1.急、慢性胃炎确诊的主要依据是什么？2.根除Hp的方案？3.自身免疫性胃炎实验室检查有什么特点？思考题1.急、慢性胃炎确诊的主要依据是什么？