2015年 · 第35卷第09期

chronic gastritis is the most common type of disease in the digestive system, mainly caused byH.pyloriMost of the chronic inflammatory reactions of gastric mucosa caused by infection are pangastritis mainly in the gastric antrum, and the gastric mucosa layer is mainly infiltrated by lymphocytes and plasma cells. Some patients have atrophy and metaplasia of intrinsic glands of gastric mucosa in the later stage^[1]。 Although the diagnosis of chronic gastritis was proposed as early as the 18th century, there has been no objective and easy to implement diagnostic criteria for a long time, which brings a lot of confusion to clinical work. Just as Lui Nong Hua^[2]It is pointed out that the diagnosis and treatment of chronic gastritis must be standardized, and the most economical and effective treatment for patients with chronic gastritis will bring greater benefits. A multi-center survey conducted by the Gastrointestinal Dynamics Group of the Gastroenterology Branch of the Chinese Medical Association examined the symptom spectrum, gastric function, presence or absence of chronic gastritisH.pyloriThe relationship between infection, gastric mucosa erosion and symptoms has been studied in detail and beneficially discussed, especially at the end of the article, it is pointed out that if there are psychological disorders, psychological treatment should be strengthened, and anti-anxiety and anti-depression treatment should be applied if necessary^[3]。 At present, there are many consensus and guidelines on the diagnosis and treatment of chronic gastritis in China from Sydney diagnostic standards to the new Sydney system abroad, but why can't the diagnosis and treatment of chronic gastritis be standardized? Is there a problem with the operability of the diagnostic criteria, or is the physician not diagnosing according to the consensus? It is proposed to focus on the related problems of chronic gastritis from another aspect, that is, from the perspective of psychosomatic medicine, and also involve the problem of functional dyspepsia (FD).

It is well known that mental and psychological factors play an important and critical role in the etiology and pathogenesis of gastrointestinal diseases, especially functional gastrointestinal disorder (FGID)^[1]。 With the development of our society, people's social activities and lifestyle have undergone huge and rapid changes, which makes the prevalence of gastrointestinal diseases related to mental stress gradually increase. Dealing with digestive psychosomatic health problems has increasingly become a great challenge in the clinical practice of digestive specialties. However, even if there are combined mental and psychological disorders or psychosomatic factors, the main complaints and treatment appeals of patients who visit gastroenterologists are mainly gastrointestinal symptoms. If the related psychosomatic health problems are not properly handled, it is difficult to achieve ideal results in the treatment of gastrointestinal diseases. So, how to improve the ability to deal with digestive, mental and physical health? In theory, the key is to improve the ability to identify such problems. In fact, in traditional textbooks or publications on diagnosis and treatment skills of gastroenterology, there is no easily understood and mastered symptom classification system related to psychosomatic factors. From the perspective of "dualism" of psychiatry, psychology and neurogastroenterology, this paper sorts out the clinical manifestations of digestive psychosomatic health problems in the digestive system, and classifies these clinical manifestations with the thinking of convenient clinical intervention, and puts forward practical coping strategies one by one.

With the development of society and medical progress, many diseases can no longer be explained by physiology. Therefore, scholars gradually shifted their attention from the disease to the patient themselves, and put forward the biological-psychological-social medical model^[1]。 This model links the environment, psychological factors and the occurrence and outcome of diseases. Through this holistic comprehensive understanding, it can explain various phenomena of diseases more scientifically, provide new diagnosis and treatment ideas and methods, and also facilitate more effective treatment of patients.

FD is a common clinical functional gastrointestinal disorder (FGID). FD refers to the presence of one or more dyspeptic symptoms originating in the gastroduodenal region and the absence of any organic, systemic, or metabolic disease that can explain these symptoms. FD can be divided into postprandial distress syndrome (PDS) and epigastric pain syndrome (EPS) according to the symptomatic characteristics. The prevalence of FD in western countries ranged from 11.5% to 14.7%^[1]19.8% ~23.5% in China^[2]。 The pathogenesis of FD is still unclear, and it is related to physiological, psychological and social factors. FD often overlaps with other FGIDs. Studies have found that overlapping patients have a high incidence and severe degree of mental disorders^[3]； Combination of FD with anxiety, depression and other mental disorders is common, which increases the difficulty of treatment and medical expenses^[4]。 In the 1990s, Haug et al.^[5]Comparing outpatient patients with FD and duodenal ulcer with healthy patients, it was found that 87% of FD patients had mental and psychological abnormalities, including depression, anxiety, hypochondriasis, conversion hysteria, social malcoping, etc., while only 25% of duodenal ulcer patients had mental and psychological abnormalities. Studies show that 17.4% of general patients in gastroenterology clinics in China meet the diagnosis of mental disorder DSM-IV depression disorder, and 9.4% meet the diagnosis of anxiety disorder; The incidence of depression and/or anxiety disorders in gastroenterology department of Peking Union Medical College Hospital was 18.8%^[6]。 54% of patients with depressive disorder had complaints of digestive discomfort, which was much higher than that of the control group without mental disorders; 24% of patients with depressive disorder had visited at least one outpatient clinic for gastrointestinal symptoms in the past 1 year, which was significantly higher than that in the control group^[7]。 Clinically, it is found that FD is the same as other FGIDs, and its severity is related to whether it is combined with mental and psychological disorders. The Rome III guidelines propose that the evaluation of FGID should be combined with gastrointestinal and extragastrointestinal symptoms, the degree of impaired body function, disease-related cognition and behavior, etc.; Studies have found that nearly half of FGID patients are associated with mental and psychological problems. Mental and psychological disorders can cause or aggravate gastrointestinal symptoms by affecting gastrointestinal tract motility, visceral hypersensitivity and brain-intestinal axis function, and affect patients' perception of disease and response to treatment^[9]。 Therefore, the effective identification and treatment of FD and its related psychological disorders is an indispensable and very important link in clinical treatment of FD.

Clinical departments often encounter such patients. They have many complaints of physical symptoms, but after various examinations, they can't find organic diseases that can explain these symptoms. Modern Western medicine describes it as medically unexplained symptom (MUS). FGID can be regarded as the MUS of gastroenterology. Biomedicine, which is dominated by science and culture, may believe that patients with MUS are not free of diseases, but they are limited to the current scientific and technological ability to fail to detect them, and the diseases behind them will definitely be found in the near future or the distant future. We should not doubt science, but must recognize the great contribution of science to medicine, and timely and actively transform and apply relevant science and technology to clinical medical practice. What we should think about is how to re-understand the multiple attributes of medicine and solve the problems that science can't solve at present more reasonably. It is obviously unreasonable to understand and treat FGID with multidimensional problems from a single dimension^[1]。 As Professor Fan Daiming said, medicine is far more complex than science. It is even more impossible for clinical gastroenterologists to wait for scientific discovery and explanation before using biomedical means to treat FGID patients, which account for more than 40% of gastroenterology outpatients. Explanation is a major problem in clinical medicine. Every patient needs explanation, but it has to be diagnosed and treated without explanation. Getting out of the dualistic model of separation of mind and body in biomedicine, understanding and dealing with FGID from the monism of mind and body can bring dawn to the clinical work of gastroenterologists. Psychosomatic holistic medicine believes that for the symptoms of FGID, it is not that there is no explanation, but a defect in the medical evaluation system^[2]。 The single biomedical evaluation system only understands the biological significance of symptoms, which has serious shortcomings. From the biomedical point of view, the doctor's task has been basically completed after excluding organic diseases, but from the practical point of view of clinical medicine, excluding organic diseases itself has no therapeutic significance, the patient's consultation will not stop, and the doctor's task has not been completed. Somatic symptoms also have very complex psychological meanings, including the physical symptoms of various mental illnesses and the negative symbolic meaning (symbolic meaning) after the patient's excessive or misinterpretation. This is exactly what gastroenterologists face, and it needs to be paid attention to and actively faced.

Chronic pain is clinically common, and gastroenterology is no exception. Chronic biliary tract disease is more common in patients with epigastric and right epigastric pain, among which patients with depression and anxiety often see the doctor repeatedly^[1]After long-term treatment, even removing the gallbladder still can't relieve the pain. In the past, physicians usually neglected the role of negative psychological and emotional factors. In recent years, the research on chronic pain associated with depression and anxiety has received increasing attention^[2]。 Compared with healthy controls, patients with chronic acalculous cholecystitis (CAC) had more pronounced symptoms of depression and anxiety^[3]。 However, there are few reports on antidepressant anxiety treatment in CAC patients. This study was to observe the efficacy of sertraline, a new antidepressant, in patients with CAC associated with depression, anxiety and chronic pain.

With the development of portal hypertension in hepatitis B cirrhosis, the incidence of decompensated cirrhosis increases, and the 5-year survival rate is only 14% ~28%^[1,2]。 Although hepatic vein pressure gradient (HVPG) is the gold standard for assessing portal hypertension, it is not suitable for widespread clinical application because of its invasiveness and high cost. hepatic Doppler ultrasound combined with microbubble angiography can detect liver hemodynamic changes non-invasively, simply, cheaply and accurately, and ultrasound parameters such as hepatic vein-damping index (HV-DI) and hepatic vein arrival time (HVAT) in patients with liver cirrhosis are correlated with HVPG, which can reflect the changes of portal vein pressure^[3,4,5]。 For patients with chronic hepatitis B, long-term antiviral therapy with nucleoside (acid) analogues such as lamivudine is effective and safe, which can reduce the incidence of liver decompensation and hepatocellular carcinoma, and delay the progression of chronic hepatitis B, advanced liver fibrosis and cirrhosis^[6]。 At present, there are few reports on the effects of long-term antiviral therapy on the hemodynamics of portal hypertension in patients with hepatitis B cirrhosis. In this study, a prospective, non-randomized controlled method was used to evaluate the effect of long-term antiviral therapy on liver hemodynamics in patients with hepatitis B cirrhosis using ultrasound.

acute pancreatitis (AP) is a common acute abdominal disease in clinic. Most patients' condition is self-limiting, but 20% ~30% of patients still have dangerous clinical experience, and the mortality rate is 5% ~10%^[1]。 Timely and accurate diagnosis of AP is the key to guide treatment and improve prognosis. Although pancreatic function indicators represented by amylase play an important role in the rapid diagnosis of AP, amylase is also elevated in a variety of other non-AP diseases^[2]And its elevation degree is not related to the severity of the disease, and cannot reflect the severity of the disease and prognosis. At present, the commonly used clinical methods to predict the condition of AP patients include acute physiology and chronic health Evaluation (APACHE) Ⅱ, Ranson score, bedside index for severity in acute pancreatitis (BISAP), computed tomography severity index (CTSI), etc., but all have certain limitations.

At present, IBD is considered to be an intestinal damage caused by abnormal response of intestinal mucosal immune system, including UC and CD, which is caused by environmental, genetic, infective and immune factors. The sources of vitamin D mainly include the endogenous pathway generated by skin transformation by ultraviolet irradiation, and the exogenous pathway by ingesting foods and drugs rich in vitamin D. In addition to the traditional effects of regulating calcium and phosphorus metabolism, vitamin D has been found to have a wide range of effects on fighting infection and regulating immunity in recent years. It is related to many autoimmune diseases (such as IBD) and has attracted much attention.

Liver cancer is one of the common malignant tumors, which is a serious threat to human health^[1]。 Hepatocellular carcinoma, as the main type of liver cancer, is prone to recurrence and metastasis after surgical resection. cancer stem cell theory suggests that abnormal differentiation of liver precursor cells into live cancer stem cells (LCSC) induces the occurrence and development of liver cancer^[2]。

H.pyloriInfection is an important cause of diseases such as dyspepsia, chronic gastritis, peptic ulcer, gastric cancer and gastric MALT lymphoma. In recent years,H.pyloriThe eradication rate decreased significantly, and the main reason for the eradication failure wasH.pylori is resistant to antibiotics. Therefore, the detectionH.pylori resistance, targeted selection of sensitive antibiotics is eradicatedH.pyloKey to ri. Traditional detectionH.pyloThe main method of ri resistance is drug sensitivity test, but the consumables of E-test are expensive, the paper diffusion method lacks effective judgment standard, and the agar dilution method has high requirements for operation technology; In addition,H.pyloriIt has harsh requirements for culture, slow growth under micro-aerobic conditions, and is not suitable for clinical routine development; And drug sensitivity test cannot identifyH.pyloriStrain gene mutation sites. With the development of molecular biology technology, PCR, fluorescence in situ hybridization (florescencein-situhybridization, FISH), gene chips, DNA sequencing and other molecular biology technologies have been gradually usedH.pyloriDetection of drug resistance.