Chronic atrophic gastritis (CAG) is a chronic disease characterized by atrophy of gastric mucosal epithelium and glands, thinning of mucosa, thickening of mucosal muscle layer with intestinal epithelial hyperplasia (IM) and atypical hyperplasia (AH), and IM and AH are closely related to the occurrence of gastric cancer, especially intestinal gastric cancer, therefore, effective treatment and control of CAG is considered to be the key stage of early prevention of gastric cancer [1]. The treatment of CAG in modern medicine is mostly based on the etiology and pathology of the disease and adopts the treatment rules and methods of “complete eradication of Hp bacterial infection, strengthening the barrier function, promoting epithelial growth, promoting gastric peristalsis and reducing intestinal fluid reflux” [2], which has improved the symptoms of CAG to a certain extent, but more scholars gradually feel that modern medicine has a significant impact on the development of CAG. “However, more scholars gradually feel the confusion of modern medicine in the diagnosis and treatment of chronic atrophic gastritis [3]. Is the process of atrophy and intestinalization occurring irreversible? Does eradication of Hp prevent gastric mucosal atrophy and intestinalization? Can the control and reduction of the unfavorable factors that lead to intestinalization reverse atrophy and intestinalization by changing the environment of the mucosa? The above scientific questions have been controversial. Recently, many studies have reported that TCM has shown efficacy advantages in the treatment of CAG [4]; the Consensus Opinion on Chronic Gastritis in China formulated by the Chinese Society of Gastroenterology in 2006 also clearly stated that “TCM treatment can broaden the treatment pathway of chronic gastritis” [5]. However, while there are many reports of the superior efficacy of TCM in the treatment of CAG, is there also a “confusion” in the field of TCM? How to get rid of the “confusion” and achieve a breakthrough in treatment, it is necessary to analyze and discuss the current situation of its treatment. 1, modern medicine so far there is no CAG-specific treatment measures and methods So far, people have been looking for drugs and methods to control the development of CAG and reverse gastric mucosal atrophy and intestinalization, and have done a lot of attempts and exploration. Some foreign scholars have observed that the atrophic mucosa can be completely regressed after Hp eradication and continued negative for 12 years, while the entericized mucosa also tends to gradually regress, but may require longer follow-up [6], and it is believed that whether atrophy and entericization can be reversed remains to be confirmed by more studies [7]. In China, Hu Pinjin et al. showed through animal experiments that early eradication of Hp could prevent the formation of atrophic gastritis, but had no reversal effect on the formed atrophic gastritis [8]. Another study showed that oral treatment with teprenone for 24 wk significantly improved the clinical symptoms and endoscopic manifestations and histopathology of CAG [9], but there is also a lack of evidence whether teprenone can control atrophy. The Consensus Opinion on Chronic Gastritis in China recognized that folic acid intervention in atrophic gastritis over 10 years of clinical use has shown to improve histological status and result in a significantly lower incidence of gastric cancer than controls; green tea rich in tea polyphenols (EGCG) has been shown to reduce the risk of developing gastric cancer in atrophic gastritis; and allicin reduces the incidence of gastric cancer in atrophic gastritis caused by Helicobacter pylori [5], but some of these studies are still There is a lack of multicenter, randomized double-blind controlled studies [3], and the evidence for its improvement of gastric mucosal atrophy needs to be further expanded and validated. Despite the great efforts of modern medicine on the prevention and reversal studies of CAG, it seems to be evident that there are still no specific therapeutic measures and methods for CAG so far, therefore many scholars seem to expect to seek some breakthrough from the perspective of TCM. Many scholars have advocated strengthening the spleen and benefiting the qi, emphasizing nourishing the yin and generating fluid, advocating draining the liver and stomach, advocating clearing heat and dampness, and often activating blood circulation and resolving blood stasis, as well as different or similar cleansing of the liver and fire, cooling the blood and removing toxins. There are also different or similar methods of clearing liver and fire, detoxifying heat, cooling blood and resolving blood stasis, benefiting the temperature …… and many other concurrent treatments; there are also many methods from the perspective of disease identification, for Hp infection, inhibiting gastric mucosal atrophy, stopping gastric mucosal intestinalization and combining single herbal medicine to identify the disease [4], Chinese medicine has its own insights of flexible treatment, although it broadens the treatment of CAG, but in the pang However, the advantages and disadvantages of these treatments are difficult to be clearly judged, and most of the reported results have not yet been confirmed by long-term clinical follow-up and microscopic tests. The author has summarized more than 1,500 papers on the treatment of CAG in the past 8 years and found that there are 78 different names of Chinese medicine treatments, and 57 mixed treatments and concurrent treatments; another set of research data shows that more than 400 papers reported that the treatment of CAG involves more than 350 kinds of Chinese medicine prescriptions, and another 64 papers reported that there are 59 kinds of empirical prescriptions of famous doctors [4]. Such a wide range of remedies and prescriptions inevitably leads to confusion in the current state of clinical treatment and confusion in the choice of application by physicians, and even to questions. Therefore, I believe that how to grasp the main pulse of TCM treatment of CAG, and how to select the advantageous therapies from many TCM treatments, so as to change the confusing situation of TCM treatment classification, first of all, we should establish the framework structure of the main treatment directions of CAG, and determine the priority of TCM treatments according to the advantages, which should be an important premise for the selection of treatments in the clinical treatment of CAG in TCM. The instability and lack of “consensus” on the efficacy of TCM prescriptions is one of the important reasons why TCM “results” are difficult to be truly promoted The improvement of CAG symptomatology and clinical efficacy of TCM is an indisputable fact. Although the effect of TCM on the reversal of gastric mucosal atrophy or intestinalization has gradually attracted the attention and interest of scholars, there are still many controversies. A typical example is the “Gastric Fuchun” tablet developed by Hu Qing Yu Tang in Hangzhou, which is increasingly used by Chinese and Western clinicians in clinical practice [10-12]; it seems to indicate that TCM has shown potential efficacy advantages in anti-gastric mucosal atrophy. However, in recent years, there have been many reports of better efficacy than the control group “Gastric Fuchun” [13-15]; even the results of Meta-analysis of the literature database of Gastric Fuchun for CAG concluded that “the efficacy and safety of Gastric Fuchun for CAG cannot be concluded with certainty” [16]. The results of a Meta-analysis of the literature database on the treatment of CAG even concluded that “the efficacy and safety of Gastrovacrol for the treatment of CAG cannot be concluded with certainty” [16]. Recently, the author searched more than 40 Chinese medicine patents for the treatment of CAG through the “Patent Network” of the State Intellectual Property Office, but no specific prescription for the treatment of CAG pathology has been found, nor has it been transformed and developed into a specific drug for the treatment of CAG. Even if the inventions are authorized, there is still a lack of accepted evidence whether they have been confirmed by randomized multicenter double-blind controlled studies. Therefore, even if the “diagnosis and treatment plan” and “results” are obtained through TCM scientific research, it is still difficult to be “digested, absorbed” and promoted and applied in the clinic. Therefore, the author believes that stable TCM treatment protocols and regular prescriptions and medications, as well as reproducible efficacy, are the keys to the widespread recognition and application of TCM “results”. The “consensus of diagnosis and treatment” of modern medicine is generally accepted by modern TCM clinics, but do the diagnosis and treatment protocols of TCM need to be accepted by Western medicine? Can they be accepted? These questions have always been controversial in the Chinese medicine community. Whether the advantages or possible breakthroughs of TCM in the treatment of CAG need to be recognized and accepted by the domestic and international gastroenterology community is also the key to the promotion and application of the advantages of TCM in the treatment of CAG. Recently, academician Wang Yongyan of the Chinese Academy of Traditional Chinese Medicine suggested that the core issue of “complexity intervention” in TCM is “consensus efficacy”, “What is consensus efficacy? That is, the efficacy that is recognized by Chinese medicine and Western medicine; the efficacy that is recognized by Chinese people and by foreigners is called consensus efficacy” [17]. Therefore, whether the clinical efficacy of TCM can obtain “consensus” or not will, to a certain extent, determine whether the advantages of TCM in treating CAG are widely recognized and accepted. The lack of quantifiable and controllable procedures in the current TCM “treatment protocol” and the lack of representative prescriptions for treatment priorities is one of the reasons why it is difficult to be accepted by the domestic and international gastroenterology community. In May 2002, the State Drug Administration revised the “Guidelines for Clinical Research on New Chinese Medicines for Chronic Atrophic Gastritis”. In September 2006, the Chinese Society of Traditional Chinese Medicine, Branch of Spleen and Gastrointestinal Diseases, prepared and published the Guidelines for the Treatment of Digestive Diseases in Traditional Chinese Medicine, which described in detail for the first time the methods, drugs, clinical efficacy criteria, and efficacy criteria of evidence for the treatment of CAG, making In 2009, the Chinese Society of Traditional Chinese Medicine (CCM) Branch of Spleen and Gastrointestinal Diseases issued the latest “Consensus on Chinese Medicine Treatment of Chronic Atrophic Gastritis”, which set out (1) six types of evidence-based treatment, (2) principles of medication addition and reduction, (3) types and methods of using proprietary Chinese medicines, and (4) other therapies (acupuncture, diet, psychology). This “consensus” has to some extent standardized the principles, procedures and main treatments of CAG in TCM, but it is still difficult to operate in clinical practice. How to avoid subjective differences in judgment in the identification of symptoms? How to add or subtract dosage according to the evidence? Should we choose tonics or adult medicines? How to choose the dosage of tonics? Which is better and which is worse in the combination of various proprietary medicines? In addition, the use of acupuncture, psychological and dietary methods in “other therapies” is also not clear. It can be seen that the current “consensus” or “program” of TCM treatment for CAG is only a theoretical generalization and overview, and lacks standardized and operable procedures, which still cannot reflect the dominant direction of TCM treatment and the primary and secondary arrangement of selected therapies. The instability of choosing treatment methods, the uncertainty of drug dosage, and the non-standardization of addition and subtraction according to the evidence are prone to the deviation of “methods and results” in the clinical implementation. The current “treatment plan” of TCM is based on the classification of the six types of symptoms into multiple TCM pathological mechanisms, and the selection of treatment methods and prescriptions from the parallel six treatment rules [18], which lacks the direction of treatment focus and primary and secondary judgments, and is subjective in its treatment mode, will inevitably produce bias in the diagnosis of the types of symptoms and the selection of medication. The complexity of its operation mode and the interference of individual experience and subjective speculation in clinical treatment have led to the current situation of irregular treatment. Looking at the clinical and literature reports, most doctors still rely on their own “clinical experience”, “medication characteristics”, “teacher’s habit” or “exclusive views The non-standardized application of “adding and subtracting with the evidence, flexible and adaptable” may be a characteristic of TCM, but the lack of standardized and unified diagnostic and treatment methods and primary and secondary standards for the use of prescriptions and drugs naturally results in “a hundred flowers competing for beauty However, the lack of standardized and unified diagnosis and treatment methods and primary and secondary standards for the use of prescriptions and drugs will naturally result in a situation where “a hundred flowers are competing” and “flowers are blooming inside the wall”, which is difficult to be regulated and unified in the real sense. Recently, in the process of implementing the National Eleventh Five-Year Plan for Science and Technology “Optimization of Clinical Treatment Plan for Chronic Atrophic Gastritis”, the author first summarized the literature on 8056 cases of CAG patients treated by Chinese medicine in the past 10 years. The most basic treatment for CAG was the method of strengthening the spleen and benefiting the qi, which accounted for 35 or 45% of the total treatment composition, followed by the method of draining the liver and harmonizing the stomach (22 or 24%) and the method of benefiting the qi and nourishing the yin (16 or 68%) [19], and these three treatments exceeded more than 70% of the total composition of the TCM treatment for CAG. Therefore, it seems safe to assume that there are objectively representative treatments and prescriptions of primary and secondary importance in the treatment of CAG in TCM. In our opinion, it is important to refine and optimize the main and secondary treatments and prescriptions that are representative of TCM, to develop standardized, refined and stable treatment protocols, to clarify the indications and their application scope, and to achieve wide acceptance of the “consensus protocols” and “consensus efficacy” in the treatment of CAG. On the basis of “consensus efficacy”, it may be the focus of TCM program to be widely recognized and accepted and can be promoted. 5. The judgment of TCM efficacy based on macroscopic symptoms is also an important factor that makes it difficult to get wide recognition of efficacy. However, with the development of TCM technology, in 2009, the “Consensus opinion on TCM treatment of chronic atrophic gastritis” [19] has added to its efficacy assessment criteria (1) pathological histological changes (including atrophy, IM, ATP, chronic inflammation, activity and Hp), (2) characteristic changes of gastric mucosal lesions under gastroscopy (major and minor lesions), (3) symptom evaluation (major and minor symptoms), and (4) quality of life scale assessment ( In addition, the “consensus opinion” of Chinese medicine also provides for “pathological biopsy sampling”, suggesting that five specimens should be taken according to the new Sydney classification system [19]. This is undoubtedly a scientific progress in TCM diagnosis and treatment by incorporating microscopic efficacy indicators. However, is the site and depth of biopsy before and after treatment precisely the same? Will the relative blind examination before and after treatment bring biopsy site deviation? It has become an important scientific issue in the current Chinese and Western gastroenterology community to determine the accuracy of pathological changes such as atrophy, intestinalization, and atypical hyperplasia. Therefore, it is crucial to ensure the accuracy, depth, and consistency of the biopsy site before and after treatment, and to avoid the localization bias brought by blind examination, which is the key to the recognized efficacy of Chinese medicine. Recently, the development of “gastric mucosal calibrated biopsy” (MTB) technology in the National 863 Program, presided over by Professor Jianmin Si of Zhejiang University, has been applied to determine the efficacy of CAG [20], and if MTB technology can be introduced to determine the efficacy of TCM on CAG, it will make the evaluation of TCM efficacy more objective and provide strong “consensus” evidence. If MTB technology can be introduced into the efficacy of TCM for CAG, it will make the evaluation of TCM efficacy more objective and provide strong “consensus” evidence. Recently, academician Wang Yongyan pointed out that the real demand for change in the direction of TCM discipline pointed out the direction of TCM discipline development, such as “continuously improving the evaluation method system of TCM efficacy in order to obtain consensus evidence-based evidence, so as to improve the quality of TCM theory. This will improve the scientific and technical accessibility of TCM theories” and “establish standardized domestic and international standards for the TCM industry and continuously improve international academic influence” [22]. It can be seen that the development of TCM and the promotion and application of TCM results should be based on “consensus evidence-based” and “common standards at home and abroad” in order to be gradually accepted both at home and abroad, and the advantageous methods and drugs of TCM for CAG and their promotion and application Chinese medicine is no exception. How to promote the advantages of TCM and gradually gain widespread recognition and acceptance at home and abroad, and how to overcome the “confusion” of TCM in the treatment of CAG, we think we can try to start from the following aspects. (1) To condense the main directions and representative prescriptions for the treatment of CAG in TCM, and to standardize the standards of medication and structure of dosage. ② The formulation of the program should be based on the “combination of prescriptions and evidence” and “combination of disease and evidence”, i.e., the prescriptions and medicines of TCM are in line with the representative main types of evidence, and the “combination of disease and evidence” is based on the “combination of prescriptions and evidence”. The “combination of prescription and evidence” means that the structure of the TCM evidence is in accordance with the main pathological process of gastric mucosal atrophy, and the evolution from traditional evidence-based treatment to the combination of evidence-based treatment and disease identification. ③The TCM protocols developed, the clinical treatment pathways should be clear, standardized and standardized; the selection of prescriptions and medicines, the rules of addition and subtraction, the doses used, the scope of adaptation should be determined, and the operable procedures should be clear and easy to grasp for the general Chinese and Western medicine and digestive community. ④ Clinical research and clinical trial design should be in accordance with the Good Clinical Practice (GCP) and DME principles (design, measurement and evaluation). ⑤ Clinical efficacy should be judged on the basis of “consensus evidence-based”, and the “consensus on efficacy” and its explanation of the language of efficacy mechanism should be in accordance with “common domestic and international standards”. If so, the objective efficacy of TCM in the treatment of CAG will be recognized and accepted by the gastroenterology community, the TCM treatment protocol for CAG will be widely recognized and promoted, and the advantages of TCM in the treatment of CAG will be better developed.