Chronic gastritis is a common and frequent disease, and since most patients do not have any symptoms, it is difficult to obtain the exact prevalence rate, which is initially estimated to be roughly parallel to the prevalence of H. pylori infection in the local population and may be higher or slightly higher than that of H. pylori infection. At present, there are still some blind spots in the diagnosis and treatment of this disease at the grassroots level, and some places lack the necessary screening equipment and drugs. To overcome the difficulties and improve the correct diagnosis and treatment rate, the author believes that it is necessary to grasp several key issues in the clinical decision-making process.
Key point 1 Avoid falling into the misunderstanding of diagnosis and treatment
When community doctors treat patients with chronic gastritis, there are often 2 distinct phenomena: first, because most patients with chronic gastritis do not have any symptoms, no examination and treatment are given; second, once chronic gastritis, especially atrophic gastritis, is detected, excessive examination and treatment are given because of the fear of cancer. The inconsistency between doctors’ statements during health promotion leaves patients at a loss, and in serious cases even leads to medical disputes. Therefore, community physicians should pay attention to the following issues during the diagnosis and treatment of chronic gastritis.
Pay attention to the problem of missed diagnosis and misdiagnosis
Most patients with chronic gastritis are asymptomatic, and those with symptoms are mainly dyspeptic and non-specific; the presence or absence of dyspeptic symptoms and their severity do not correlate significantly with the endoscopic findings of chronic gastritis and the histological grading of the gastric mucosa. There was no significant difference in clinical manifestations and psychosomatic status between patients with chronic gastritis with dyspeptic symptoms and those with functional dyspepsia.
Changes in diagnostic names
In the new “Chinese Consensus on Chronic Gastritis”, the previous term “superficial gastritis” was renamed “chronic non-atrophic gastritis”, and the term “heterogeneous hyperplasia” was renamed “intraepithelial neoplasia”. “Intraepithelial neoplasia”.
Biopsy points to note
Biopsies should be taken in 2 or more pieces, depending on the lesion and the need. The endoscopist should provide the pathologist with information on the site of sampling, what is seen endoscopically and a brief medical history. When available, biopsies can be performed under pigmented or electronically stained magnified endoscopic guidance. The biopsy focus site should be located at the gastric sinus, gastric angle, the lesser curvature side of the gastric body and the suspected lesion. To facilitate monitoring and follow-up of the lesion, a definitive biopsy of the gastric mucosa can be considered when available.
Focus 2 Follow individualized principles of diagnosis and treatment
According to the consensus opinion, the diagnosis of chronic gastritis relies mainly on endoscopy and histological examination of gastric mucosal biopsy, especially the latter is more valuable in confirming the diagnosis. The diagnosis of chronic gastritis should be aimed at identifying the cause, and routine testing for H. pylori is recommended.The treatment of chronic gastritis is aimed at relieving symptoms and improving the inflammatory response of the gastric mucosa.
Treatment should be tailored to the etiology as much as possible and follow the principle of individualization.
Asymptomatic, H. pylori-negative chronic non-atrophic gastritis does not require specific treatment.
The management of dyspeptic symptoms in chronic gastritis is the same as in functional dyspepsia.
H. pylori eradication is recommended for H. pylori-positive chronic gastritis with gastric mucosal atrophy, erosions or dyspeptic symptoms.
Those with gastric mucosal erosion and/or symptoms such as acid reflux and epigastric pain may be treated with acid suppressants, H2 receptor antagonists or proton pump inhibitors depending on the severity of the condition or symptoms.
If epigastric fullness, nausea or vomiting are the main symptoms, prokinetic drugs can be used. If there are obvious symptoms of indigestion such as bloating and poor appetite associated with eating, digestive enzyme preparations can be considered.
For those with bile reflux, prokinetic agents and/or gastric mucosal protectors with bile acid binding effects can be used. Gastric mucosal protective agents can improve the gastric mucosal barrier and promote the healing of gastric mucosal erosion, but their effect on symptom improvement is still controversial.
Patients with chronic gastritis who have obvious psychosomatic factors may use antidepressants or anxiolytics appropriately.
Some vitamins with antioxidant effect, selenium and folic acid may have some effect in treating chronic atrophic gastritis, delaying its development and reducing the cancer rate. However, it is important to use the medication under medical supervision, including testing and monitoring blood folate and vitamin B12 concentrations before and during medication administration.
Point 3 About chronic atrophic gastritis
The prevalence of chronic atrophic gastritis generally increases with age, with chronic atrophic gastritis present in 50% to 70% of older adults. This is mainly associated with H.
pylori infection rate increases with age, and atrophy, intestinal epithelial metaplasia (referred to as intestinalization) and ageing are also related.
The incidence of chronic atrophic gastritis is high in China, and the diagnosis of chronic atrophic gastritis has endoscopic diagnosis and pathological diagnosis, while the compliance rate of atrophic gastritis judged by endoscopy and pathological diagnosis is low, and the confirmation of diagnosis should be based on pathological diagnosis.
The inflammatory response and immune response caused by long-term H. pylori infection can cause gastric mucosal atrophy and intestinalization in some patients, and H. pylori infection has the role of promoting the development of atrophic gastritis to gastric cancer.
Most chronic atrophic gastritis is stable, but moderate to severe cases may progress further without any intervention, and those with intraepithelial neoplasia have a varying increased risk of developing gastric cancer. Chronic atrophic gastritis is often combined with intestinalization and, in a few cases, intraepithelial neoplasia, which can develop into gastric cancer in a few cases after a long period of evolution. Most of the low-grade intraepithelial neoplasia is reversible and less often malignant to gastric cancer.
Chronic atrophic gastritis, especially those with moderate to severe intestinal or intraepithelial neoplasia, should be followed up with regular endoscopy and pathological histological examination. Patients with chronic atrophic gastritis with moderate to severe atrophy and intestinalization should be followed up about once a year; those with low-grade intraepithelial neoplasia should be followed up about once every 6 months; those with high-grade intraepithelial neoplasia should be confirmed immediately for cancer, and endoscopic treatment or surgery should be performed after confirmation.
Eradication of H. pylori can eliminate H. pylori-associated chronic gastritis activity.
pylori-associated chronic gastritis activity and reduce the degree of chronic inflammatory response, which can slow down the progression of precancerous lesions (atrophy, intestinalization and intraepithelial neoplasia) and possibly reduce the risk of gastric cancer; it can also reverse the atrophy in some patients, but intestinalization is difficult to reverse.
Focus 4 Enhance health education
Diet
Let patients eat light food that is easy to digest and pay attention to vitamin and other trace elements supplementation. Eat regularly, and may eat small and frequent meals. Encourage patients to summarize a set of suitable recipes with their personal habits to avoid causing damage to the gastric mucosa. Make patients quit smoking and drinking, and forbid eating raw, cold, hard, spicy and other stimulating foods. Eat less fried, smoked and pickled foods, and eat more fresh vegetables and fruits.
Medication use
Tell patients to avoid taking medicines such as aspirin, indomethacin, erythromycin and adrenocorticosteroids as much as possible. Educate patients to use medications under the guidance of a doctor and avoid self-medication.
Exercise
Encourage patients to strengthen physical exercise to enhance physical fitness. The intensity of exercise should be within the range of adaptation of their own body.
Work and rest
Educate patients to go to bed early and wake up early, and not to stay up late; regulate their moods, keep them relaxed, and try to avoid anxiety and irritability.
Psychological guidance
Patients with chronic gastritis, especially chronic atrophic gastritis, often have a fear of cancer, and when there is indigestion, loss of appetite, weight loss, the suspicion is more serious, in addition to the necessary endoscopy, should be correctly psychological guidance.