胃镜与病理诊断慢性萎缩性胃炎相关性的调查

萎缩性胃炎是癌前病变，尤其在伴有胃黏膜肠上皮化生及异型增生时。因此萎缩性胃炎的准确诊断、定期随访，对监测胃癌的发生非常重要。而我们在实际工作中发现萎缩性胃炎的胃镜与病理一致性较差，为了更好地诊断萎缩性胃炎，了解其内镜下突出的特点，我们进行了如下调查。     

胃镜下黏膜红白相间以白为主的表现与萎缩性胃炎的关系

萎缩性胃炎(CAG)的胃镜下表现多种多样，缺乏特征性改变，但胃黏膜红白相间以白为主的表现仍是很多医生初步诊断萎缩性胃炎的主要依据之一。本文通过对30例患者资料的分析进一步探讨两者的关系。     

萎缩性胃炎的胃镜随访研究

慢性萎缩性胃炎的转归问题,尤其是与胃癌的关系问题,是人们所关心的重要问题,国内外都有不少的论著和研究。为了阐明馒性萎缩性胃炎与胃癌的关系,我科自1975年至1992年初对慢性萎缩性胃炎进行了随访。     

慢性萎缩性胃窦炎胃镜诊断与病理诊断的关系研究

我院自2000—04／2000—10胃镜诊断为慢性萎缩性胃窦炎72例,同时行病理学检查,现对胃镜诊断和病理诊断的关系进行了初步探讨。     

萎缩性胃炎胃镜表现与病理学改变的相关性分析

萎缩性胃炎（CAG）因常伴随肠腺化生（IM）和不典型增生（AH）两个癌前病变而受重视。胃镜是诊断CAG最主要的检查手段之一,但其表现与病理学改变是否相关仍有争论。近期我们分析了CAG胃镜下的特征性表现与病理学改变的关系。现报告如下。     

慢性萎缩性胃炎内镜诊断与病理结果对照分析

目的 探讨胃镜下表现对萎缩性胃炎(CAG)的诊断价值。方法 对55例内镜诊断的CAG与病理结果进行对照分析，分别计算镜下CAG各种表现对病理诊断CAG、肠上皮化生及异型增生的敏感性和特异性。结果 55例患者中内镜诊断CAG30例、CAG合并浅表性胃炎(CAG)25例；病理诊断CAG36例、CSG8例、CAG合并CSG11例。内镜直视与病理诊断相比较，符合率为85．45％。CAG内镜下的各种表现对病理诊断的敏感性为12．77％～51．06％。镜下某些表现对CAG的病理诊断有较高的特异性，如花斑样改变和扁平隆起分别达87．50%、75．00％；白相为主、血管透见伴扁平隆起及花斑样改变伴隆起糜烂的特异性均达l00%。镜下粗糙不平、颗粒样改变对诊断肠上皮化生的价值较大，其敏感性和特异性分别达66．67％、71．74％。白相为主、血管透见对诊断异型增生的敏感性达71．74％；隆起糜烂对诊断异型增生的特异性达68．89％。结论 胃镜直视下的花斑样改变，粗糙不平、颗粒样改变，白相为主、血管透见分别对CAG、肠上皮化生、异型增生的病理诊断有较高的价值，但正确的诊断仍必须结合胃镜直视与黏膜活检。     

慢性萎缩性胃炎胃镜随访发现胃窦早癌一例

患者女,68岁,因“活动性慢性萎缩性胃炎伴结肠型肠上皮化生”长期在我院行胃镜随访。患者8年前因上腹部不适来我院行胃镜检查,胃角、胃窦活检病理提示活动性慢性萎缩性胃炎伴结肠型肠上皮化生;7年前活检病理显示中度慢性萎缩性炎伴结肠型肠上皮化生;6年前活检病理提示中一重度慢性萎缩性炎伴结肠型肠上皮化生及部分腺管上皮轻度不典型增生;随后4年胃镜复查所见均为较典型的慢性萎缩性胃炎表现（图1）,活检病理均提示中一重度萎缩性胃炎伴肠上皮化生（图2）。     

萎缩性胃炎与非萎缩性胃炎胃黏膜基因表达谱的对照研究

目的 萎缩性胃炎是癌前疾病之一，常为非萎缩性胃炎演变的后果。应用生物芯片技术观察萎缩性胃炎和非萎缩性胃炎胃黏膜组织基因表达谱的差异，探讨萎缩性胃炎发生的分子生物学机制。方法 连续登记在门诊接受胃镜检查的萎缩性胃炎和非萎缩性胃炎患者227例，男143例，女84例，平均年龄48．6岁(16～72岁)。胃镜检查时获取胃体和胃窦黏膜活检标本进行病理学检查，其余活检黏膜组织液氮冻存。根据病理学检查结果将冻存的组织标本分成萎缩性胃炎组和非萎缩性胃炎组，分别抽提两组组织的总RNA，逆转录制备荧光cDNA探针，用含有8464条人类体细胞基因模板的表达谱cDNA芯片进行杂交实验。结果 与非萎缩性胃炎相比，萎缩性胃炎的活检胃黏膜组织中165项基因的表达水平上调2倍以上，460项的表达水平下调50％以上。表达下调者占73．6％。结论 基因表达谱生物芯片技术可以获得萎缩性胃炎胃黏膜组织基因在表达水平上改变情况的较全面的信息；萎缩性胃炎涉及多基因在表达水平上的改变。     

慢性萎缩性胃炎胃粘膜血流量的研究

为探明慢性萎缩性胃炎者胃粘膜血供情况，应用激光多普勒血流仪测定２８例胃炎患者的胃粘膜血流量（ＧＭＢＦ），其中慢性萎缩性胃炎组１５例，非萎缩性胃炎组１３例。发现：（１）两组从十二指肠球部至胃底部，随着位置的升高，ＧＭＢＦ逐渐增加；（２）胃大弯侧高于小弯侧（前组胃窦部相反）；（３）前组各部位ＧＭＢＦ均低于后组（Ｐ＜０．０５，胃窦大弯侧Ｐ＜０．０１）。说明慢性萎缩性胃炎ＧＭＢＦ较非萎缩性胃炎明显降低，推测这是其发病及难以治愈的重要原因之一。     

胃动素动物实验及临床初步观察

对１３只兔右心室血浆、肠系膜上静脉血浆、胃液和十二指肠液及６７例健康人和慢性萎缩性胃炎（ＣＡＧ）患者血浆和十二指肠液胃动素（ＭＯＴ）含量的测定表明：１．兔十二指肠液、血浆与胃液ＭＯＴ的浓度比为４∶２∶１，三者间两两比较相差显著（Ｐ＜０．０５）；２．健康人血浆及十二指肠液ＭＯＴ含量分别为１４１．６±５７．３ｐｍｏｌ／Ｌ和３９５．１±１８０．４ｐｍｏｌ／Ｌ。后者是前者的２．８倍；３．ＣＡＧ患者血浆ＭＯＴ含量与健康组比较无显著性差异，十二指肠液的ＭＯＴ含量升高特别显著（Ｐ＜０．００１），且与萎缩及肠化程度有关。说明ＭＯＴ的分泌除有内分泌方式外，还有外分泌或腔内分泌途径，腔内分泌途径可能对维持与调节胃肠道局部运动功能有重要的生理及临床病理学意义。     

ATROPHIC GASTRITIS IN THE AGED

The incidence of gastritis and the correlation of this finding with the presence of circulating parietal cell antibodies and gastric secretory function was studied in 24 asymptomatic subjects aged over 6o years. A gastric biopsy examination, a maximal histamine-stimulation test, a test for parietal cell antibody and a Schilling test were performed on each subject. The biopsy specimens were examined by histological and histochemical methods. The gastric juice was assayed for acid and intrinsic factor content, and the serum iron and vitamin B₁₂ levels were measured. All but one subject showed some degree of chronic atrophic gastritis. Close correlation was found between gastric secretory function, the histological changes in the gastric mucosa and the reduction in specialized cells demonstrated on histochemical examination. Two subjects presented a “pre-pernicious anæmia” picture with gross reduction in intrinsic factor secretion, a degree of malabsorption of vitamin B₁₂ but no evidence of vitamin B₁₂ deficiency; a very similar case not included in the series is described to illustrate the diagnostic problem which may occur with hæmatological evidence of vitamin B₁₂ deficiency as a result of atrophic gastritis. Serum iron levels were reduced in some cases with severe atrophic gastritis. Antibodies to parietal cells occurred with increasing frequency as the changes in the gastric mucosa became more marked. Atrophic gastritis is a common finding in the “normal” aged male even in the absence of gastrointestinal symptoms, and a clinical picture simulating early pernicious anæmia may occur as a result of “normal ageing” of the gastric mucosa.     

肥大细胞与幽门螺杆菌相关性胃炎

本文对３５６例慢性胃炎（胃镜活检标本）组织中幽门螺杆菌（ＨＰ）与肥大细胞（ＭＣ）关系进行了探讨。结果发现：伴ＨＰ感染的胃炎中ＭＣ计数较之无ＨＰ感染者明显增多（Ｐ＜０．０１）。且ＨＰ越多，组织中的ＭＣ数量也越多。本文结果提示：胃粘膜组织中ＭＣ可能在ＨＰ相关性胃炎的病变发展中有重要意义。     

CLINICAL EVALUATION OF NODULAR GASTRITIS IN ADULTS

Background: Nodular gastritis (NG) was considered a physiological change with little pathological significance, mostly in young women. In recent years, however, it has been often reported in patients with Helicobacter pylori (H. pylori) infection, or in patients with gastroduodenal ulcer/gastric cancer, suggesting possible clinical significance. Methods: From July 2003 to July 2006, 59 patients were diagnosed with NG among 32 404 patients examined endoscopically. The incidence of NG was evaluated in relation to age, sex, H. pylori infection status, symptoms leading to endoscopy, associated lesions in the upper digestive tract at the time of NG diagnosis, and existence of other systemic conditions. Results: The NG patients consisted of 13 out of 18 152 (0.07%) male patients and 46 out of 14 252 (0.32%) female patients, with a mean age of 45.3 ± 17.7 years. All 28 patients who were examined for H. pylori infection were positive. Endoscopic examination was performed for precordial pain and upper abdominal pain in 24 (40.7%) patients, symptoms of gastroesophageal reflux disease in eight (13.6%) patients, and symptoms of functional dyspepsia in six (10.2%) patients. NG was associated with duodenal ulcer in eight (13.6%) patients, hyperplastic gastric polyps in five (8.5%), gastric ulcer in one (1.7%), and gastric cancer in one (1.7%) patient. Conclusion: NG is a specific gastritis resulting from H. pylori infection that may be strongly associated with H. pylori‐related lesions.     

ENDOSCOPIC IDENTIFICATION OF HELICOBACTER PYLORI GASTRITIS IN CHILDREN

Aim: The role of endoscopic findings in deciding whether to biopsy the gastric mucosa of children remains unclear. The present study attempted, for the first time, to identify the value of endoscopic features for diagnosis of Helicobacter pylori (Hp) infection in children. Methods: Hp status of consecutive children receiving esophagogastroduodenoscopy (EGD) was established by combinations of histology, ¹³C‐urea breath test, and serum Hp immunoglobulin (Ig)G antibody. After routine EGD using a conventional endoscope, the presence of RAC (regular arrangement of collecting venules) was scored by close observation, which was carried out at two sites of lower corpus lesser curvature and upper corpus greater curvature. RAC‐positive was defined as the presence of minute red points in a regular pattern. Antral nodularity was also scored as present/absent. Results: Eighty‐seven consecutive children (38 boys, median age 13 years, range 9–15 years) were evaluated; 25 (29%) were Hp positive. Antral nodularity was seen in 21 (84%) all of whom were Hp positive. The RAC‐negative pattern based on examination of the upper and lower corpus yielded a sensitivity, specificity, positive predictive value and negative predictive value for the presence of Hp infection of 100%, 90%, 81%, and 100%. Magnifying endoscopy confirmed that the RAC pattern corresponded to collecting venules in the gastric corpus. Conclusions: The absence of RAC pattern suggests that gastric mucosa biopsies should be taken despite otherwise normal‐appearing gastric mucosa for the diagnosis of Hp infection in children.     

慢性胃炎患者幽门括约肌压力测定及其与辨证分型关系的研究

本研究采用内镜测压术，检测８０例证属脾胃虚弱型和肝胃不和型的慢性胃炎患者幽门括约肌压力变化。结果，脾胃虚弱型患者幽门括约肌收缩振幅降低、收缩频率减慢，而肝胃不和型患者幽门括约肌收缩振幅增高、收缩间期延长，与正常对照组比较均具非常显著意义（Ｐ＜０．０１）。表明幽门括约肌压力参数变化可作为慢性胃炎辨证分型的胃动力学参考指标，并可指导临床治疗用药和疗效评定。     

关于胆汁反流性胃炎诊断标准的探讨

探讨多指标诊断胆汁反流性胃炎的临床价值。５９例慢性胃炎患者按胆汁反流程度分为非反流性胃炎组和１～３级反流性胃炎组，１０名健康志愿者为对照组。测定胃液胆汁酸浓度（ＧＣ，μｇ／ｍｌ）和ｐＨ值，胃粘膜病理积分（ＲＦＩ）和组织学Ｈｐ检出率。胃γ闪烁扫描作为诊断胆汁反流金标准。随着反流程度的加重，胃液ＧＣ和ｐＨ值增高，胃炎程度加重，Ｈｐ检出率减低（上述以２～３级反流意义显著）。以ＧＣ＞５８μｇ／ｍｌ、ｐＨ≥３．０、ＲＦＩ＞９作为异常界值，则胃炎程度与胃液胆汁酸浓度和ｐＨ值呈显著正相关，与Ｈｐ的检出率呈显著负相关。胃镜下２～３级反流、胃液ＧＣ＞５８μｇ／ｍｌ和ｐＨ≥３．０、组织学ＲＦＩ＞９和Ｈｐ阴性有诊断价值，以两项或两项以上综合指标作为标准，诊断的准确性明显提高。