07-1 中国慢性胃炎共识意见 2012

主堡逍丝盘盍！！！ｉ生！旦墓ｉ！鲞筮！塑竺！也』垡ｇ！』！！坚！Ｙ！！！ｉ！∑！！：ｉｉ！堕！：！

胃炎Ｈ”５…ｏ

在慢性胃炎患者中，海尔曼螺杆菌的感染率约为０．１５％～ｏ．２０％。与Ｈ．ｐｙｌｏｒｉ感染相比，海尔曼螺杆菌感染者胃黏膜炎性反应程度较轻，根除海尔曼螺杆菌也可使胃黏膜炎性反应消退口１Ｉ。海尔曼螺杆菌感染也可引起胃黏膜相关淋巴样组织（ｍｕｃｏｓａ—ａｓｓｏｃｉａｔｅｄｌｙｍｐｈｏｉｄｔｉｓｓｕｅ，ＭＡＬＴ）淋巴瘤‘５０Ｉ。

五、临床表现、诊断与治疗

１．多数慢性胃炎患者无任何症状口２｜，有症状者主要为消化不良。且为非特异性；消化不良症状的有无和严重程度与慢性胃炎的内镜所见及胃黏膜的病理组织学分级无明显相关性［５３｜。

部分慢性胃炎患者可出现上腹痛、饱胀等消化不良症状。有消化不良症状的慢性胃炎与功能性消化不良患者在临床表现和精神心理状态上无显著差异［５“。有学者发现８５％的功能性消化不良患者存在胃炎，且５１％合并Ｈ．ｐｙｌｏｒｉ感染［５…。该数据在不同地区因Ｈ．ｐｙｌｏｒｉ感染率而异。部分慢性胃炎患者可同时存在胃食管反流病和消化道动力障碍，尤其在一些老年患者，其下食管括约肌松弛和胃肠动力障碍尤为突出［Ｉ６Ｉ。流行病学研究显示，约５０％～７０％的老年人存在慢性萎缩性胃炎∞…。不同内镜表现和病理组织学结果的患者症状无特异性，且症状的严重程度与内镜所见和病理组织学分级无明显相关性∞３Ｉ。

２．慢性胃炎的确诊主要依赖内镜检查和胃黏膜活检，尤其是后者的诊断价值更大。

鉴于多数慢性胃炎患者无任何症状，即使有症状也缺乏特异性，而且缺乏特异性体征，因此根据症状和体征难以做出慢性胃炎的正确诊断。慢性胃炎的确诊主要依赖内镜检查和胃黏膜活检组织学检查，尤其是后者的诊断价值更大（详见本文前述的“内镜部分”和“病理组织学部分”的相关内容）。

３．慢性胃炎的诊断应力求明确病因。建议常规检测Ｈ．ｐｙｌｏｒｉ。

Ｈ．ｐｙｌｏｒｉ感染是慢性胃炎的主要病因，建议作为慢性胃炎病因诊断的常规检测。在慢性胃炎中，胃体萎缩者血清胃泌素Ｇ１７水平显著升高，胃蛋白酶原工或胃蛋白酶原工和Ⅱ的比值降低；胃窦萎缩者，前者降低，后者正常；全胃萎缩者则两者均降低。因此，血清胃泌素Ｇ１７以及胃蛋白酶原工和Ⅱ的检测有助于判断胃黏膜有无萎缩和萎缩的部位口８“ｏｊ。萎缩性胃体炎可由Ｈ．ｐｙｌｏｒｉ感染或自身免疫所致口１。６２Ｉ，怀疑自身免疫所致者建议检测血清胃泌素、维生素Ｂ，。以及壁细胞抗体、内因子抗体等。

４．慢性胃炎的治疗目的是缓解症状和改善胃黏膜炎性反应；治疗应尽可能针对病因，遵循个体化原则。

慢性胃炎的治疗目的是缓解症状和改善胃黏膜组织学。慢性胃炎消化不良症状的处理与功能性消化不良相同。无症状、Ｈ．ｐｙｌｏｒｉ阴性的慢性非萎缩性胃炎无需特殊治疗；但对慢性萎缩性胃炎，特别是严重的慢性萎缩性胃炎或伴有上皮内瘤变者应注意预防其恶变。

５．Ｈ．ｐｙｌｏｒｉ阳性的慢性胃炎有胃黏膜萎缩、糜烂或消化不良症状者，推荐根除Ｈ．ｐｙｌｏｒｉ。

Ｈ．ｐｙｌｏｒｉ相关性胃炎是否均需根除Ｈ．ｐｙｌｏｒｉ尚缺乏统一意见。国内Ｈ．ｐｙｌｏｒｉ感染处理共识邓胡推荐对有胃黏膜萎缩、糜烂或有消化不良症状者根除Ｈ．ｐｙｌｏｒｉ。前已述及，慢性胃炎的主要症状为消化不良，其症状应属于功能性消化不良。根除治疗可使Ｈ．ｐｙｌｏｒｉ阳性的功能性消化不良患者症状得到长期缓解［６４‘６…。根除Ｈ．ｐｙｌｏｒｉ可使胃黏膜组织学得到改善［６６Ｉ，对预防消化性溃疡和胃癌等有重要意义，对改善或消除消化不良症状也具有费用一疗效比优势。

６．有胃黏膜糜烂和（或）以反酸、上腹痛等症状为主者，可根据病情或症状严重程度选用抗酸剂、Ｈ２受体拮抗剂或质子泵抑制剂（ｐｒｏｔｏｎｐｕｍｐｉｎｈｉｂｉｔｏｒ，ＰＰＩ）。

胃酸和胃蛋白酶在胃黏膜糜烂（尤其是平坦糜烂）、反酸和上腹痛等症状的发生中起重要作用，抗酸或抑酸治疗对愈合糜烂和消除上述症状有效。抗酸剂作用短暂；包括奥美拉唑、埃索美拉唑、兰索拉唑、雷贝拉唑和泮托拉唑等在内的ＰＰＩ抑酸作用强而持久，可根据病情或症状严重程度选用［６７Ｉ。某些患者选择适度抑酸治疗可能更经济且不良反应较少。

７．根据患者症状可选用促动力药、消化酶制剂等。上腹饱胀、恶心或呕吐等为主要症状者可用促动力药，而伴胆汁反流者则可应用促动力药和（或）有结合胆酸作用的胃黏膜保护剂。具有明显的进食相关的腹胀、纳差等消化不良症状者。可

中国慢性胃炎共识意见(2012年,上海)

作者：中华医学会消化病学分会， 房静远， 刘文忠， 李兆申， 杜亦奇， 纪小龙， 戈之铮， 李延青，姒健敏

作者单位：中华医学会消化病学分会,房静远,纪小龙,姒健敏(200001,上海交通大学医学院附属仁济医院消化科上海市消化疾病研究所)， 刘文忠,李兆申(上海长海医院消化科)， 杜亦奇(解放军武警总医院病理科

)， 戈之铮(山东大学齐鲁医院消化科)， 李延青(浙江大学医学院邵逸夫医院消化科)

刊名：

中华消化杂志

英文刊名：Chinese Journal of Digestion

年，卷(期)：2013,33(1)

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