从病理学角度谈慢性胃炎与功能性消化不良的诊断与治疗

慢性胃炎与FD临床上两者容易造成混淆,理论上,慢性胃炎属于器质性病变,内镜下胃黏膜有糜烂或萎缩病变,病理活检表现为活动性炎症,以中性粒细胞浸润和腺上皮损害为标志;萎缩性胃炎则表现为固有腺体的减少、肠上皮化生和异型增生等。FD内镜虽也可诊断为慢性浅表性胃炎,但胃黏膜并无明显糜烂或萎缩病变;病理活检可出现淋巴细胞浸润,但并无活动性炎症和腺上皮病变等特征。掌握两种疾病在病因、诊断和治疗上的不同特点,对规范慢性胃炎和FD的诊治有重要意义。     

中国慢性胃炎诊治指南（2022年，上海）撤回

慢性胃炎是常见病,认识其病因和临床表现,规范其诊断和治疗,以及预防其癌变一直为临床医师所重视。本指南在过去3次慢性胃炎诊治共识意见的基础上,参考国际上胃黏膜癌前病变处理指南等相关共识和指南,制定符合我国国情的慢性胃炎诊断和治疗指南,具有临床价值和可行性。本指南由中华医学会消化病学分会发起,中华医学会消化病学分会消化系统肿瘤协作组主要成员作为召集人和撰写者,遵循国际通用的指南制定原则和方法,在广泛征集消化内科和内科医师意见的基础上,针对有关慢性胃炎的九大类临床问题,有循证依据地给出53项推荐意见,旨在提高我国临床医师对慢性胃炎这一多发病的诊治管理水平。     

中国慢性胃炎诊治指南（2022年，上海）

慢性胃炎是常见病,认识其病因和临床表现,规范其诊断和治疗,以及预防其癌变一直为临床医师所重视。本指南在过去3次慢性胃炎诊治共识意见的基础上,参考国际上胃黏膜癌前病变处理指南等相关共识和指南,制定符合我国国情的慢性胃炎诊断和治疗指南,具有临床价值和可行性。本指南由中华医学会消化病学分会发起,中华医学会消化病学分会消化系统肿瘤协作组主要成员作为召集人和撰写者,遵循国际通用的指南制定原则和方法,在广泛征集消化内科和内科医师意见的基础上,针对有关慢性胃炎的九大类临床问题,有循证依据地给出53项推荐意见,旨在提高我国临床医师对慢性胃炎这一多发病的诊治管理水平。     

功能性消化不良与慢性胃炎

临床医生在医疗实践和基础研究中一直对功能性消化不良(functional dyspepsia,FD)的诊断感到困惑,尤其难以将FD与慢性胃炎患者区别开来.尽管罗马Ⅲ工作委员会在功能性胃肠病罗马Ⅲ标准中已明确FD的诊断标准,但在消化内镜开展比较广泛的我国,符合罗马Ⅲ诊断标准的FD患者在经胃镜检查后,尤其是经病理组织学检查后,几乎所有的受检者都会被发现胃黏膜具有炎症改变,使FD与慢性胃炎的鉴别更为困难.因此,目前有必要从胃肠神经病学的角度对FD重新认识.     

幽门螺杆菌临床研究中有争议的若干问题

幽门螺杆菌(Hp)阳性的功能性消化不良是否应根除Hp?在临床上，有时将慢性胃炎与功能性消化不良(FD)作为“同义词”，应该说两存在差异。慢性胃炎强调胃黏膜组织学改变，多数(75％～85％)病人并无消化不良症状；而FD则强调消化不良症状，部分病人可无慢性胃炎。     

抑酸深度与酸相关性疾病

胃酸相关性疾病包括胃十二指肠溃疡病、胃食管反流病（GERD）、应激性溃疡、卓艾综合征及一部分慢性胃炎和功能性消化不良（FD）.其中溃疡病（包括应激性溃疡）、GERD和卓艾综合征的发病与胃酸攻击绝对相关,故治疗上疗效与抑酸强度呈正相关.而慢性胃炎和FD因其病因多样性和不确定性,其抑酸在治疗上的地位及作用无肯定结论.     

胃液pH值在慢性胃炎和功能性消化不良中的变化

目的了解在慢性胃炎和功能性消化不良(FD)这两种疾病的患者胃液中胃酸的pH值变化及胃液分泌功能的改变,进而正确指导抑酸剂的临床合理应用。方法采用胃镜下黏膜观察及活检病理,108例符合条件患者分为三组:慢性非萎缩性胃炎组(53例)、慢性萎缩性胃炎组(15例)、功能性消化不良组(40例)。30例健康体检者作为正常对照组。所有纳入患者行胃液pH值检测。结果与正常对照组相比,慢性萎缩性胃炎组、慢性非萎缩性胃炎组和功能性消化不良组患者胃液pH均升高,但差异无统计学意义(P>0.05)。三组之间的胃液pH值水平无统计学差异(P>0.05)。结论在针对慢性胃炎和FD患者临床治疗中,持续大量应用质子泵抑制剂是不适宜的。     

幽门螺杆菌与慢性胃炎和消化性溃疡

<正>距离幽门螺杆菌(helicobacter pylori,Hp)首次被发现和分离已经30年了,发现者Warren和Marshall也因此获得了2005年的诺贝尔医学与生理学奖。Hp感染与慢性胃炎、消化性溃疡、胃癌、胃黏膜相关淋巴组织淋巴瘤的发生密切相关,其中对临床诊治最为重要的首推消化性溃疡的治疗,而在临床常见的慢性胃炎中,Hp的作用也极为重要。幽门螺杆菌感染与慢性胃炎慢性胃炎是消化系统常见疾病,在Hp感染率     

中西医结合治疗功能性消化不良30例

功能性消化不良(FD)是一种临床常见的内镜检查无器质性病变的疾病,目前分为溃疡型和动力障碍及非特异性型,治疗上主要以促动力剂、抗酸剂等为主.自1999年9月～2002年6月作者共诊治FD患者90例,结果报告如下.     

小儿慢性胃炎48例的误诊分析

目的通过分析小儿慢性胃炎误诊的原因,以提高对小儿慢性胃炎的早期诊治水平。方法回顾性分析我院儿内科收治的48例慢性胃炎患儿,通过分析其主诉、体征以及所做的辅助检查,结合患儿自身特殊情况,辨别误诊的原因。结果通过了解误诊原因,找到能够正确诊断的方法。结论小儿慢性胃炎可以早期诊断和治疗。     

幽门螺杆菌阴性慢性浅表性胃炎与功能性消化不良

目的　从治疗学的角度研究幽门螺杆菌 (Hp)阴性慢性浅表性胃炎 (CSG)与功能性消化不良 (FD)的关系。方法　将Hp阴性CSG患者 2 14例随机分成自身交叉治疗组和病例对照试验治疗组 ,用常用的慢性胃炎治疗方案 (甲方案 )和FD治疗方案 (乙方案 )进行自身交叉试验和病例对照试验 ,比较甲方案和乙方案的疗效。结果　在病例对照试验中 ,甲和乙方案的总有效率分别为89 2 %和 88 5 % ;在自身交叉试验中 ,甲和乙方案的总有效率分别为 81 8%和 89 8% ,甲方案和乙方案疗效比较差异无显著性 (P >0 0 5 )。结论　Hp阴性CSG与FD密切相关 ,二者可能是相同范畴的疾病。     

罗马Ⅲ标准在功能性消化不良诊断和鉴别诊断中的价值

目的 评价罗马Ⅲ标准诊断功能性消化不良(FD)的敏感性和特异性,及其在FD与常见上消化道器质性疾病鉴别诊断中的价值.方法 对2006年7至8月和2007年3至4月在内镜中心行上消化道检查的4962例患者进行连续性问卷调查,按照罗马Ⅲ标准诊断FD,根据胃镜及相应病理检查结果诊断慢性糜烂性胃炎(CEG)、胃溃疡(GU)、十二指肠溃疡(DU)及胃癌(GC)等上消化道器质性疾病,分析它们之间临床特点的差异.结果 FD、CEG、GU、DU和GC患者分别占调查总数的7.58%(376/4962)、29.99%(1488/4962)、1.89%(94/4962)、4.25%(211/4962)和4.57%(227/4962).FD患者中女性所占比例(230/376,61.17%)高于男性(146/376,38.83%,P=0.00),而器质性疾病患者中男性比例高于女性(P<0.05).FD与DU组发病年龄差异无统计学意义(P>0.05),均小于其他三组(P<0.05).FD患者早饱和餐后饱胀的发生率高于其他四种疾病.嗳气、恶心和呕吐在各疾病中的发生率差异无统计学意义(P>0.05).罗马Ⅲ标准定义下的四种FD症状(上腹痛、上腹烧灼、早饱和餐后饱胀)诊断FD的敏感度均较诊断其他疾病高(P<0.05).除上腹烧灼外,其余三种症状诊断FD的特异度均高于其他疾病(P<0.05).该四种症状诊断FD的约登指数均高于其他疾病.尤以上腹痛(0.42)和餐后饱胀(0.46)最高.结论 罗马Ⅲ标准诊断FD具有相对较高的敏感度和特异度,在FD与上胃肠道常见器质性疾病的鉴别诊断中具有一定的价值.     

Electrical bioimpedance gastric motility measurement based on an electrical-mechanical composite mechanism

AIM: To introduce a bioimpedance gastric motility measurement method based on an electrical-mechanical composite concept and a preliminary clinical application.METHODS: A noninvasive gastric motility measurement method combining electrogastrogram (EGG) and impedance gastric motility (IGM) test was used. Preliminary clinical application studies of patients with functional dyspepsia (FD) and gastritis, as well as healthy controls, were carried out. Twenty-eight FD patients (mean age 40.9 ± 9.7 years) and 40 healthy volunteers (mean age 30.9 ± 7.9 years) were involved. IGM spectrum was measured for both the healthy subjects and FD patients, and outcomes were compared in the FD patients before treatment and 1 wk and 3 wk after treatment. IGM parameters were obtained from 30 erosive gastritis patients (mean age 50.5 ± 13.0 years) and 40 healthy adults, and IGM and EGG results were compared in the gastritis patients before treatment and 1 wk after treatment.RESULTS: There were significant differences in the IGM parameters between the FD patients and healthy subjects, and FD patients had a poorer gastric motility [percentage of normal frequency (PNF) 70.8 ± 25.5 in healthy subjects and 28.3 ± 16.9 in FD patients, P < 0.01]. After 1 wk administration of domperidone 10 mg, tid, the gastric motility of FD patients was not improved, although the EGG of the patients had returned to normal. After 3 wk of treatment, the IGM rhythm of the FD patients became normal. There was a significant difference in IGM parameters between the two groups (PNF 70.4 ± 25.5 for healthy subjects and 36.1 ± 21.8 for gastritis patients, P < 0.05). The EGG rhythm of the gastritis patients returned to normal (frequency instability coefficient 2.22 ± 0.43 before treatment and 1.77 ± 0.19 one wk after treatment, P < 0.05) after 1 wk of treatment with sodium rabeprazole tablets, 10 mg, qd, po, qm, while some IGM parameters showed a tendency toward improvement but had not reached statistical significance.CONCLUSION: The electrical-mechanical composite measurement method showed an attractive clinical application prospect in gastric motility research and evaluation.     

Management of functional dyspepsia： Unsolved problems and new perspectives

The common characteristic criteria of all functional gastrointestinal (GI) disorders are the persistence and recurrence of variable gastrointestinal symptoms that cannot be explained by any structural or biochemical abnormalities. Functional dyspepsia (FD) represents one of the important GI disorders in Western countries because of its remarkably high prevalence in general population and its impact on quality of life. Due to its dependence on both subjective determinants and diverse country-specific circumstances, the definition and management strategies of FD are still variably stated. Clinical trials with several drug classes (e.g., proton pump inhibitors, H2-blockers, prokinetic drugs) have been performed frequently without validated disease-specific test instruments for the outcome measurements. Therefore, the interpretation of such trials remains difficult and controversial with respect to comparability and evaluation of drug efficacy, and definite conclusions can be drawn neither for diagnostic management nor for efficacious drug therapy so far. In view of these unsolved problems, guidelines both on the clinical management of FD and on the performance of clinical trials are needed. In recent years, increasing research work has been done in this area. Clinical trials conducted in adequately diagnosed patients that provided validated outcome measurements may result in better insights leading to more effective treatment strategies. Encouraging perspectives have been recently performed by methodologically well-designed treatment studies with herbal drug preparations. Herbal drugs, given their proven efficacy in clinical trials, offer a safe therapeutic alternative in the treatment of FD which is often favored by both patients and physicians. A fixed combination of peppermint oil and caraway oil in patients suffering from FD could be proven effective by well-designed clinical trials.     

Guidelines for diagnosis and treatment of chronic gastritis in China (2022, Shanghai)

Chronic gastritis is a commonly seen disease; clinicians have always attached to the importance of understanding its etiology and clinical manifestations, standardizing its diagnosis and treatment, and preventing its progression to cancers. Based on the consensus opinions on the diagnosis and treatment of chronic gastritis in the past three editions, and referring to the international consensuses and guidelines on the management of precancerous lesions of gastric mucosa, it is of clinical value and feasibility to formulate the guidelines for the diagnosis and treatment of chronic gastritis in line with China's national conditions. This guideline was initiated by the Chinese Society of Gastroenterology, with major members of the Cancer Collaboration Group of Chinese Society of Gastroenterology serving as the convenors and authors. Based on the internationally accepted principles and methods of guideline development and the extensive collection of opinions from gastroenterologists and physicians, 53 evidence-based recommendations are given for nine major clinical problems related to chronic gastritis, aiming to improve the diagnosis, treatment, and management of chronic gastritis.     

功能性消化不良是否需要根除幽门螺杆菌——支持的观点

幽门螺杆菌（H.pylori）阳性的功能性消化不良（FD）或非溃疡性消化不良（NUD）相当于有消化不良症状的慢性活动性胃炎，前者强调消化不良症状,后者则强调胃黏膜组织学改变。根除H.pylori可使部分患者的症状得到长期改善,胃黏膜活动性炎症消退，逆转或防止萎缩／肠化生的发展,预防胃癌和消化性溃疡，与其他治疗措施相比具有费用,疗效比优势。     

Novel mechanisms in functional dyspepsia

Functional dyspepsia (FD) is a highly prevalent but heterogeneous disorder in which multiple pathogenetic mechanisms are involved. Although there are many studies that have investigated various pathophysiologic mechanisms, the underlying casual pathways associated with FD remain obscure. The currently proposed pathophysiologic mechanisms associated with FD include genetic susceptibility, delayed as well as accelerated gastric emptying, visceral hypersensitivity to acid or mechanical distention, impaired gastric accommodation, abnormal fundic phasic contractions, abnormal antro-duodenal motility, acute and chronic infections, and psychosocial comorbidity. A greater understanding of the abnormalities underlying FD may lead to improved management. The aim of this editorial is to provide a critical overview of current pathophysiologic concepts in functional dyspepsia.     

Treatment of functional diarrhea

Opinion statement Functional diarrhea (FD), one of the functional gastrointestinal disorders, is characterized by chronic or recurrent diarrhea not explained by structural or biochemical abnormalities. The treatment of FD is intimately associated with establishing the correct diagnosis. First, FD needs to be distinguished from diarrhea-predominant irritable bowel syndrome (IBS), in which, unlike in FD, abdominal pain is a primary diagnostic criterion. Next, FD must be differentiated from the myriad organic causes of chronic diarrhea. Unlike IBS, in which a positive diagnosis can be made with an acceptable level of confidence using symptom-based criteria and minimal testing, the diagnosis of FD is still primarily a diagnosis of exclusion. Thus, the onus is on the physician to eliminate potential underlying causes, both common and uncommon, in the proper clinical setting. Once the diagnosis has been established, the clinician and patient should first focus on identifying, eliminating, and/or treating aggravating factors. These may include physiologic factors (eg, small bowel bacterial overgrowth), psychological factors (eg, stress and anxiety), and dietary factors (eg, carbohydrate malabsorption). Thereafter, appropriate treatment for functional diarrhea may be instituted. Treatment options include dietary and lifestyle modification, pharmacologic therapies, and alternative modalities. Although many of these strategies have been studied in IBS, almost none of them has been examined specifically in FD. Furthermore, given the poorly understood pathophysiologic basis of FD, these treatments primarily target a patient’s symptoms and presumed altered physiology rather than underlying etiologic mechanisms. Therefore, we stress that treatment must be approached in an individualized manner and that dietary and pharmacologic therapies should be part of a comprehensive therapeutic approach in which education and reassurance form the foundation. In general, we attempt to remove dietary triggers and recommend increased fiber intake. We then add anticholinergic, antispasmodic, antimotility, and antidiarrheal agents as the first line of pharmacotherapy. Should a patient not respond to these, and for patients who have a significant degree of psychological dysfunction, central acting agents, including antidepressants and/or anxiolytics, may be beneficial. During the treatment period, we also recommend that physicians keep an open mind. If signs or symptoms that suggest an ongoing or previously unrecognized organic process develop, then a re-evaluation of the clinical picture is indicated.     

Chronic obstructive pulmonary disease and chronic heart failure: two muscle diseases?

Chronic obstructive pulmonary disease and congestive heart failure are two increasingly prevalent chronic diseases. Although care for these patients often is provided by different clinical teams, both disease conditions have much in common. In recent decades, more knowledge about the systemic impact of both diseases has become available, highlighting remarkable similarities in terms of prognostic factors and disease management. Rehabilitation programs deal with the systemic consequences of both diseases. Although clinical research also is conducted by various researchers investigating chronic obstructive pulmonary disease and chronic heart failure, it is worthwhile to compare the progress in relation to these two diseases over recent decades. Such comparison, the purpose of the current review, may help clinicians and scientists to learn about progress made in different, yet related, fields. The current review focuses on the similarities observed in the clinical impact of muscle weakness, the mechanisms of muscle dysfunction, the strategies to improve muscle function, and the effects of exercise training on chronic obstructive pulmonary disease and chronic heart failure.