修回日期: 2005-06-10
接受日期: 2005-06-13
在线出版日期: 2005-08-28
目的: 探讨慢性萎缩性胃炎(chronic atrophic gastritis, CAG)的临床相关因素及比较临床实践中胃镜诊断与病理诊断结果的差别.
方法: 通过分析比较在我院进行胃镜及病理检查的994例患者的临床相关因素、胃镜及病理检查结果, 了解慢性萎缩性胃炎的相关因素以及胃镜诊断与病理诊断结果差别的原因.
结果: 慢性萎缩性胃炎和慢性非萎缩性胃炎在平均年龄、吸烟史、重度酗酒、既往有胃或十二指肠病史上有显著差异; 肠上皮化生和活动性炎症伴随CAG的百分比分别为91.2%、76.7%, 明显比不伴CAG的比例(分别为8.8%、23.3%)高, 二者有高度相关性(r = 0.881, P<0.005); CAG在不同部位的萎缩程度有差别: 胃窦部CAG以轻中度萎缩为主, 重度萎缩很少.而在胃体部CAG和胃窦兼胃体部CAG患者中, 重度萎缩占有的比例远较胃窦部CAG的大.正常胃黏膜与CAG内镜下诊断以及不同部位间的CAG内镜下诊断为正常胃黏膜、胃窦部CAG、胃窦兼胃体部CAG和胃体部CAG与病理诊断比较的符合率分别为52.5%、37.5%、8%、25%.
结论: 慢性萎缩性胃炎与临床多方面因素有关, 以胃窦部多见, 在病理诊断上与胃黏膜的活动性炎症及肠上皮化生有关.胃镜诊断与病理诊断的符合率不高, 要提高CAG 诊断的正确率必须在加强胃镜技术培训的同时结合黏膜病理活检.
引文著录: 陈剑鸣, 龚飞跃. 慢性萎缩性胃炎的相关因素及内镜与病理诊断比较的临床意义. 世界华人消化杂志 2005; 13(16): 2045-2047
Revised: June 10, 2005
Accepted: June 13, 2005
Published online: August 28, 2005
AIM: To investigate the clinical correlative factors of chronic atrophic gastritis (CAG), and to evaluate the significance of the comparison between the pathologic and endoscopic diagnosis of CAG.
METHODS: The clinical data of 994 patients, who received gastric endoscopic and pathologic examinations, were collected and statistically analyzed. Then the differences between the endoscopic and pathologic diagnosis of CAG were assessed.
RESULTS: There are significant differences between chronic atrophic gastritis and chronic superficial gastritis in mean age, smoking history, heavy drinking and history of gastric or duodenal diseases. The rates of intestinal metaplasia and active inflammation accompanied with CAG were significantly higher than those didn't accompanied with CAG (91.2%, 76.7% vs 8.8%, 23.3%, r = 0.881, P<0.005). The single antrum atrophy was mainly of light and moderate degree, and the rate of the severe antrum and body atrophy was markedly higher than that of the severe antrum atrophy (19.1% and 2.0%, respectively). The coincidence rates between endoscopic and pathologic diagnosis were 52.5%, 37.5%, 25% and 8%, respectively, for normality, the single antrum atrophy, the single body atrophy, and the antrum and body atrophy.
CONCLUSION: CAG is associated with multiple factors and mostly occurs in the antrum. Pathologically, the active inflammation and intestinal metaplasia were related to the occurrence of CAG. The combination of endoscopic and pathologic examination should be used to improve the diagnosis rate of CAG.
- Citation: Chen JM, Gong FY. Correlative factors of chronic atrophic gastritis and comparison of itspathologic and endoscopic diagnosis. Shijie Huaren Xiaohua Zazhi 2005; 13(16): 2045-2047
- URL: https://www.wjgnet.com/1009-3079/full/v13/i16/2045.htm
- DOI: https://dx.doi.org/10.11569/wcjd.v13.i16.2045
慢性萎缩性胃炎是以胃黏膜固有腺体萎缩为主要表现的慢性炎症, 无论在胃镜下或病理下都占较高比例, 其发生发展与年龄、幽门螺杆菌、饮食、吸烟以及伴随的其他胃病有关.萎缩性胃炎又与胃黏膜的肠上皮化生、异形增生、直至癌变有密切的关系, 故国外学者提出CAG的发展变化是胃癌演变过程中的关键环节[1,2].而在临床实践中胃镜诊断与病理诊断有一定的差别[3], 我们通过对本院消化内镜中心来诊门诊患者994例分析对以上问题作初步探讨.
收集2003-03/2003-11间来我院消化内镜中心检查之患者994例, 其中男546例, 女448例, 平均年龄为47.8±17.3岁, 所有病例均排除了消化性溃疡胃十二指肠肿瘤及其他胃十二指肠疾患.
病理下发现胃窦部萎缩158例, 占15.9%; 其中合并体部萎缩13例, 占8%, 萎缩性胃炎的平均年龄为50.6±16.2岁, 而非萎缩性胃炎占84.1%, 平均年龄45.1±17.6岁.
2.1 慢性萎缩性胃炎和慢性非萎缩性胃炎在平均年龄、吸烟史、重度酗酒、既往有胃或十二指肠病史上有差异, 上述在CAG患者中的构成百分比均明显高于慢性非萎缩性胃炎患者, 而在症状学上除了在腹痛史有所区别外, 基本没有差别(表1).
| 全部病例 | 慢性萎缩性胃炎 | 慢性非萎缩性胃炎 | P值 | |
| 纳入研究的全体患者 | 994 | 158(15.9%) | 836(84.1%) | |
| 平均年龄 | 47.8±17.3 | 50.6±16.2 | 45.1±17.6 | <0.001 |
| 有吸烟史 | 260(26.1%) | 51(32.2%) | 209(25.0%) | <0.05 |
| 有饮酒史 | 260(26.1%) | 51(32.2%) | 209(25.0%) | >0.05 |
| 重度酗酒 | 69(6.9%) | 19(12.0%) | 50(6.0%) | <0.05 |
| 既往有胃病史 | 163(16.4%) | 38(24.1%) | 125(15.0%) | <0.001 |
| 既往有往十二指肠病史 | 138(13.9%) | 38(24.1%) | 100(12.0%) | <0.05 |
| 腹痛史 | 775(78.0%) | 115(72.8%) | 660(78.9%) | <0.05 |
| 嗳气反酸史 | 319(32.1%) | 43(27.2%) | 276(33.0%) | >0.05 |
| 恶心 | 239(24.0%) | 38(24.0%) | 201(24.0%) | >0.05 |
| 呕吐 | 91(9.2%) | 16(10.1%) | 75(9.0%) | >0.05 |
| 体重减轻 | 184(18.5%) | 25(15.8%) | 159(19.0%) | >0.05 |
| 其他诊状 | 706(71.0%) | 104(65.8%) | 602(72.0%) | >0.05 |
| NSAID服用史 | 55(5.5%) | 13(8.2%) | 42(5.0%) | >0.05 |
2.2 其他病理表现伴随CAG肠上皮化生和活动性炎症伴随CAG的百分比明显比不伴CAG的比例高, 二者有高度相关性.
CAG在不同部位的萎缩程度有差别: 胃窦部CAG以轻中度萎缩为主, 重度萎缩很少, 而在胃体部CAG和胃窦兼胃体部CAG患者中, 重度萎缩占有相当的比例(表3).
| 胃窦部CAG | 胃体部CAG | 胃窦兼胃体部CAG | |
| 轻度萎缩 | 62(57.9%) | 5(55.5%) | 13(30.9%) |
| 中度萎缩 | 43(40.1%) | 2(22.2%) | 21(50.0%) |
| 重度萎缩 | 2(2.0%) | 2(22.2%) | 8(19.1%) |
不同部位的CAG内镜下诊断与病理诊断比较的符合率差别较大, 以正常胃黏膜内镜下诊断与病理诊断比较的符合率(以下简称符合率)最高, 胃窦部CAG符合率次之, 胃窦兼胃体部CAG又次之, 而胃体部CAG的符合率最低(表4).
| 内镜下组织学 | 正常 | 胃窦部CAG | 胃体部CAG | 胃窦兼胃体部CAG | 慢性浅表性胃炎(CSG) |
| 正常 | 177(52.5%) | 81(24.0%) | 5(1.5%) | 28(8.5%) | 45(13.5%) |
| 胃窦部CAG | 19(43.5%) | 16(37.5%) | 0(0.0%) | 4(9.5%) | 4(9.5%) |
| 胃体部CAG | 1(7.7%) | 4(30.7%) | 1(7.7%) | 5(38.5%) | 2(15.4%) |
| 胃窦兼胃体部CAG | 6(25.0%) | 8(33.3%) | 0(0.0%) | 6(25.0%) | 4(16.7%) |
CAG的临床因素多种多样, 目前认为其发生发展与年龄、幽门螺杆菌(H. pylori)感染[6]、饮食因素、其他胃病史及家族遗传等多种因素有关.本文就国内研究较少的年龄、饮食因素及其他胃病史做一些统计, 慢性萎缩性胃炎和慢性非萎缩性胃炎在平均年龄、吸烟史、重度酗酒、既往有胃或十二指肠病史上有差异, 说明上述因素对CAG的发生发展确实起了重要的作用.本研究显示CAG与上述因素有关, 估计其发生, 发展与上述因素的长期存在而导致胃黏膜长期受损.和细胞的营养不良及凋亡有关.另CAG与肠上皮化生及活动性炎症有关, 但其相互作用机制尚不十分清楚.
在不同部位发生的CAG的萎缩严重程度不一样, 胃窦部CAG较轻, 而胃窦并胃体部次之.胃体部CAG较重, 这与不同部位所致的CAG的类型不同有关.胃窦部多为B型CAG, 与高酸, 消化性溃疡及H pylori感染等有关.萧树东[7]认为: A型萎缩性胃炎以胃体萎缩为主的慢性胃炎, 发生在自身免疫基础上, 又称为自身免疫性胃炎, 以北欧最多见, 我国相对少见, A型CAG的发病机制与血清中的抗壁细胞和抗内因子抗体以及低胃酸有关, 二者发病的机制不同, 影响的部位亦不一样, 对胃黏膜腺体及其增生能力损害亦有明显不同, B型CAG 胃黏膜的损伤程度较A型CAG轻, 且对腺体的增生能力损害也较轻; 胃体部的CAG虽占总CAG的比例较少, 但萎缩严重程度较重.胃体部CAG被认为多为A型CAG.由于A型CAG发生在自身免疫的基础上, 故对胃黏膜增生的损伤及阻碍其修复的影响较大, 其萎缩程度较重且面积大, 不易纠正, 而且癌变的几率远较B型CAG的高.至于在临床上二者的鉴别, 主要根据病变的部位萎缩和化生的成分以及血清中的抗壁细胞和抗内因子抗体存在与否来鉴别.
在胃镜与病理诊断的比较方面, 胃镜与病理诊断的符合率不算高[8], CAG组较正常组更低.在CAG组中, 又以胃体CAG组的诊断符合率最低.考虑与下列因素有关: (1)临床操作中注气较多, 导致胃壁扩张, 黏膜扩展、变薄, 血管显露; (2)钳取活检组织过少, 未达到固有腺体层; (3)临床医生的个人经验在胃镜下表现引起的判断差异; (4)与胃黏膜的萎缩程度有关, 中重度的符合率较轻度为低, 而胃体CAG中萎缩程度较重, 故符合率也较低.
因此我们认为慢性萎缩性炎的诊断应以病理诊断为准, 胃镜下肉眼观察价值不大, 建议对于每个做胃镜检查的患者无论有无肉眼可见的黏膜的萎缩表现, 均应常规做病理活检.另外慢性萎缩性胃炎随着年龄增大发病率增加, 活动性炎症是萎缩性胃炎的主要原因之一, 并且与胃黏膜的肠化、异形增生有密切关系.由于肠化及异形增生尤其是重度异形增生是公认的癌前病变, 故及早诊治并定期复查, 有利于胃癌的早期防治.
编辑:张海宁
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