医学课件-急性胃炎内科学教学课件.ppt

1、Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege第四篇消化系统疾病第四篇消化系统疾病 胃炎 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medic

2、al The First Affiliated Hospital of Chengdu Medical CollegeCollege第四章 胃炎 第一节、急性胃炎（acute gastritis）Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege目的和要求目的和要求1.1.掌握本病掌握本病临床表现、诊断要

3、点临床表现、诊断要点以以及及防治原则防治原则2.2.熟悉熟悉本病病因、发病机制本病病因、发病机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege讲授主要内容 概述 常见病因及病理生理机制 临床表现 诊断 治疗 预后 预防Department of GastroenterologyDepartment o

4、f GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege概述概述 急性胃炎也称糜烂性胃炎、出血性胃炎、急性胃粘膜病变 临床上急性发病，常表现为上腹部症状 内镜检查可见胃粘膜充血、水肿、出血、糜烂、浅表溃疡等一过性病变 病理组织学特征为胃粘膜固有层见到以中性粒细胞为主的炎症细胞 胃病：炎性细胞浸润很轻或无，以上皮和微血管的异常改变为主Department of GastroenterologyD

5、epartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege分类分类 单纯性胃炎 糜烂出血性胃炎 腐蚀性胃炎 化脓性胃炎Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated

6、 Hospital of Chengdu Medical CollegeCollege常见病因及病理生理机制常见病因及病理生理机制 应激 药物 酒精 创伤和物理因素 十二指肠-胃反流 胃粘膜血液循环障碍Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因病因-应激应激 诱因 严重创伤、大手术、大面积烧伤

7、、脑血管意外、严重脏器功能衰竭、休克、败血症 临床表现 胃粘膜糜烂和出血 机制 胃粘膜微循环障碍、缺氧，粘液分泌减少 局部前列腺素合成不足，屏障功能损害 胃酸分泌增加，大量氢离子反渗，损伤血管和黏膜Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因病因-药物药物 非甾体抗炎药（non-steroida

8、l anti-inflammatory drug,NSAIDs）最常见，如阿司匹林、吲哚美辛；某些抗生素或抗肿瘤药物、口服氯化钾或铁剂 非甾体抗炎药 局部作用：直接损伤胃粘膜上皮层 全身作用：抑制环氧合酶（COX），抑制前列腺素产生，破坏胃粘膜屏障的完整性 肠溶剂型的NSAIDs可以引起急性胃炎Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Me

9、dical CollegeCollege病因病因-药物药物Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因病因-药物药物 抗肿瘤化疗药物 对肠黏膜产生细胞毒作用，导致严重的黏膜糜烂 合并细菌和病毒感染增加 口服氯化钾、铁剂、辣椒 直接刺激胃粘膜引起糜烂损伤Department of Gastroen

10、terologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因-酒精酒精 具有亲脂性和溶脂能力 高浓度乙醇直接破坏黏膜屏障，引起上皮细胞损害和破坏、导致黏膜内出血、糜烂和水肿 炎症细胞浸润多不明显Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated

11、Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因-创伤和物理因素创伤和物理因素 放置鼻胃管 剧烈恶心或干呕 胃内异物 食管裂孔疝 胃镜下各种止血技术 息肉摘除 大剂量放射线照射Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of C

12、hengdu Medical CollegeCollege病因-十二指肠十二指肠-胃反流胃反流 原因：上消化道动力异常、幽门括约肌功能不全、胃毕氏术后、十二指肠远端梗阻 临床表现:十二指肠内容物、胆汁、肠液和胰液反流入胃腔，其中胆汁酸和溶血卵磷脂可以损伤胃粘膜上皮细胞，引起糜烂和出血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical

13、CollegeCollege病因-胃粘膜血液循环障碍胃粘膜血液循环障碍 门脉高压性胃病 胃底静脉曲张，不能及时清除代谢产物，胃黏膜常有渗血及糜烂 胃黏膜血管炎 胃动脉栓塞后的局部区域、罕见疾病伴随胃粘膜血管炎，胃粘膜缺血，从而导致糜烂或出血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因幽门螺杆菌感

14、染幽门螺杆菌感染Hp的作用机制粘附作用：Hp具有黏附素能紧贴上皮细胞，使细胞绒毛断裂，细菌被绒毛覆盖，不易去除蛋白酶的作用：Hp可产生蛋白酶分解蛋白质，并消化上皮细胞膜，破坏黏液屏障结构尿素酶作用：Hp具有很强的尿素酶活性，将尿素分解为NH3，既能保护细菌的生长环境，又能损伤上皮细胞毒素作用：Hp具有细胞毒素相关基因蛋白(cag A)，能引起强烈的炎症反应,空泡毒素A（Vac A）细胞空泡变性免疫反应:Hp菌体细胞还可作为抗原产生免疫反应Department of GastroenterologyDepartment of GastroenterologyThe First Affiliate

15、d Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege临床表现临床表现 常见症状：上腹痛、胀满、恶心、呕吐和食欲不振 重症 呕血、黑粪、脱水、酸中毒或休克 轻者 无症状 体征：上腹部或脐周压痛，肠鸣音亢进 门静脉高压或慢性肝病的症状和体征Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The Fi

16、rst Affiliated Hospital of Chengdu Medical CollegeCollege诊断诊断 诊断：依靠病史及临床表现，内镜检查确诊 内镜下表现：弥漫分布的多发性糜烂、出血灶和浅表溃疡形成。强调内镜宜在24-48小时内进行Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege黏膜

17、红斑及出血黏膜红斑及出血：红斑位于胃底，点片状，大小不一，并可见出血灶红斑位于胃底，点片状，大小不一，并可见出血灶Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege黏膜出血黏膜出血：胃底部黏膜广泛出血，点状或小片状，并密集融合成片，色鲜红胃底部黏膜广泛出血，点状或小片状，并密集融合成片，色鲜红Depart

18、ment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege黏膜出血黏膜出血：胃窦及胃体交界处黏膜广泛出血，点片状，色红胃窦及胃体交界处黏膜广泛出血，点片状，色红Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Ho

19、spital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege黏膜糜烂、出血黏膜糜烂、出血：胃底黏膜广泛、糜烂出血，渗出的血液附于黏膜表面，色暗红胃底黏膜广泛、糜烂出血，渗出的血液附于黏膜表面，色暗红Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of

20、Chengdu Medical CollegeCollege鉴别诊断鉴别诊断 急性胆囊炎 急性胰腺炎 早期阑尾炎Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗 病因治疗 针对原发病和病因采取防治措施去除病因，停止一切对胃有刺激的饮食和药物 对处于严重应激状态的疾病，除治疗原发病外，应常规予抑酸或

21、粘膜保护药物 对于服用NSAID的患者视情况予H2RA/PPI或米索前列醇预防 暂时禁食或流质饮食，多饮水Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗 对症处理解痉解痉东莨菪碱、普鲁本辛、东莨菪碱、普鲁本辛、654-2654-2止吐止吐甲氧氯普胺甲氧氯普胺10mg im10mg im或多潘立酮

22、或多潘立酮10mg tid10mg tid抑酸抑酸H H2 2RARA或或PPIPPI纠正水、电解质失衡，呕吐、腹泻严重者应输液纠正水、电解质失衡，呕吐、腹泻严重者应输液存在上消化道大出血者按上消化道出血治疗原则采取综存在上消化道大出血者按上消化道出血治疗原则采取综合治疗合治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical Col

23、legeCollege预后预后 多数胃粘膜糜烂和出血可自行愈合及止血 少数发展为溃疡，并发症增加 通常对药物反应良好Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege预预 防防 停用不必要的NSAIDs治疗 应激状态、需要长期服用阿司匹林或氯吡格雷等，可预防性给予H2RA 骨关节病患者，可选择性COX-2

24、抑制剂（塞来昔布、美洛昔康），减少对COX-1的抑制 倡导文明的饮食习惯，避免酗酒 门静脉高压性胃病可给予PPI，严重者考虑介入治疗Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege第二节第二节 慢性胃炎慢性胃炎 目的和要求 1.掌握本病临床表现、诊断要点以及防治原则 2.熟悉本病病因、发病机制Depar

25、tment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege概概 述述 胃粘膜色泽不均、颗粒状增殖及黏膜皱襞异常 组织学以显著炎症细胞浸润、上皮增殖异常、胃腺萎缩及瘢痕形成 病变轻者不需要治疗，当上皮增殖异常、胃腺萎缩时应积极治疗 幽门螺杆菌（Hp)感染是最常见原因Department of Gastroenterology

26、Department of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制 Hp感染 定居于黏液层与胃窦黏膜上皮细胞表面，一般不侵入胃腺和固有层 避免胃酸的杀菌作用和免疫机能的清除 产生尿素酶，分解尿素，产生氨，改变局部微环境Department of GastroenterologyDepartment of GastroenterologyThe Firs

27、t Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege 病因和发病机制病因

28、和发病机制-HpHp感染感染 Hp的作用机制粘附作用：Hp具有黏附素能紧贴上皮细胞，使细胞绒毛断裂，细菌被绒毛覆盖，不易去除蛋白酶的作用：Hp可产生蛋白酶分解蛋白质，并消化上皮细胞膜，破坏黏液屏障结构Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因和发病机制病因和发病机制-HpHp感染感染尿素酶作用

29、：Hp具有很强的尿素酶活性，将尿素分解为NH3，既能保护细菌的生长环境，又能损伤上皮细胞毒素作用：Hp具有细胞毒素相关基因蛋白(cag A)，能引起强烈的炎症反应,空泡毒素A（Vac A）细胞空泡变性免疫反应:Hp菌体细胞还可作为抗原产生免疫反应Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病

30、机制病因及发病机制-HpHp感染感染疾病发展取决于毒株毒力宿主个体差异胃内微生态环境Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制-十二指肠十二指肠-胃反流胃反流“漏屋顶漏屋顶”假说假说中国古话：中国古话：“屋漏更逢夜雨屋漏更逢夜雨”Department of Gastro

31、enterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制-十二指肠十二指肠-胃反流胃反流 胃肠慢性炎症、消化吸收不良及动力障碍所致长 期反流，可导致胃粘膜慢性炎症Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated

32、Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制-自身免疫自身免疫 壁细胞抗体（PCA)导致壁细胞总数减少，胃酸分泌减少 内因子抗体（IFA)导致内因子不能与维生素B12形成复合出现巨幼细胞贫血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Aff

33、iliated Hospital of Chengdu Medical CollegeCollege病因及发病机制病因及发病机制-年龄因素和胃黏膜营养因子年龄因素和胃黏膜营养因子缺乏缺乏 胃黏膜退行性改变 老年人胃黏膜小血管扭曲，小动脉玻璃样变性，管腔狭窄 胃黏膜营养不良、分泌功能下降和屏障功能降低 胃黏膜修复再生功能降低 长期消化吸收不良、食物单一、营养缺乏，炎症慢性化，上皮异常增生及胃腺萎缩Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu

34、Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理 慢性非萎缩性胃炎（chronic non-atrophic gastritis，CNAG）黏膜红黄相间，或黏膜皱襞肿胀增粗 慢性萎缩性胃炎（chronic atrophic gastritis，CAG）黏膜色泽变淡，皱襞变细而平坦，粘液减少，黏膜变薄，有时可透见血管 Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospi

35、tal of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理CNAGCNAG黏膜红斑：黏膜红斑：红斑呈片状，较密集地分布于胃窦四壁红斑呈片状，较密集地分布于胃窦四壁Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medi

36、cal CollegeCollege胃镜及组织学病理CAGCAG：轻度并黏膜糜烂轻度并黏膜糜烂Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理CAGCAG：黏膜变薄，血管透见黏膜变薄，血管透见Department of GastroenterologyDepartment of Gast

37、roenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理CAGCAG黏膜粗糙伴点状出血：黏膜粗糙伴点状出血：胃窦部黏膜粗糙，局部以白相为胃窦部黏膜粗糙，局部以白相为主，伴散在出血主，伴散在出血Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu

38、 Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理 慢性胃炎分类 胃窦炎 多由Hp感染引起 胃体炎 多与自身免疫有关，病变主要累及胃体和胃底 全胃炎 可由Hp感染扩展而来Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical Co

39、llegeCollege胃镜及组织学病理 胃镜活检部位Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理-炎症 炎症活动性分度 轻度：粘膜固有层有少数中性粒细胞浸润 中度：中性粒细胞较多存在于粘膜层，可见于上皮细胞、小凹细胞或腺管上皮内 重度：中性粒细胞较密集或除中度所见外还可见小凹脓肿

40、Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理-炎症 慢性炎症分度 轻度：慢性炎症细胞较少并局限于粘膜表层，不超过粘膜层的1/3 中度：慢性炎症细胞较密集，不超过粘膜层的2/3 重度：慢性炎症细胞密集，占据粘膜全层 Department of GastroenterologyDepar

41、tment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理-化生化生 化生 胃黏膜表层上皮和腺上皮被杯状细胞和幽门腺细胞取代 肠上皮化生 杯状细胞的肠腺取代了胃固有腺 假幽门腺化生 泌酸腺的颈黏液细胞增生，形成幽门腺样腺体Department of GastroenterologyDepartment of GastroenterologyThe First Aff

42、iliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理-萎缩萎缩 胃粘膜萎缩主要表现 胃粘膜固有层腺体（幽门腺或泌酸腺）数量减少甚至消失，伴纤维组织增生、粘膜肌增厚，严重者胃粘膜变薄 萎缩组织学有两种类型 化生性萎缩 固有腺体被肠化或假幽门腺体替代 非化生性萎缩 胃粘膜固有腺体被纤维组织或纤维肌性组织或炎性细胞浸润引起固有腺体数量减少Department of GastroenterologyDepartment of Gastroen

43、terologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege胃镜及组织学病理胃镜及组织学病理-异型增生异型增生 不典型增生(dysplasia)上皮内瘤变 细胞在增生的过程中过度增生和分化缺失，增生的上皮细胞拥挤、有分层现象，核增大失去极性，有丝分裂象增多，腺体结构紊乱。分为轻、中、重三度，轻者可逆转为正常，重者不易于高分化腺癌区别。中度以上的不典型增生被认为可能是癌前病变 化生、萎缩及异常增生被视为胃癌前状态Dep

44、artment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege临床表现临床表现 多数患者无症状或症状很轻 部分病人表现为消化不良的症状：中上腹不适、饱胀、钝痛、烧灼痛、食欲不振、嗳气、泛酸、恶心等 恶性贫血者有全身衰弱、疲软、明显厌食、体重减轻、贫血等Department of GastroenterologyDepart

45、ment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege诊诊 断断 胃镜及组织学检查是慢性胃炎诊断关键 Hp检测 非侵入性13C-或14C-尿素呼气试验、血清Hp抗体、粪便查Hp等 侵入性 快速尿素酶试验、嗜银染色或苏木紫-曙红染色、直接涂片染色、微需氧培养等Department of GastroenterologyDepartment of GastroenterologyTh

46、e First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege诊诊 断断 血清抗壁细胞抗体、内因子抗体和维生素B12水平测定 空腹血清维生素B12浓度为300-900ng/LDepartment of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hosp

47、ital of Chengdu Medical CollegeCollege治 疗 不需要药物治疗 非活动性、轻度慢性浅表性胃炎 需要药物治疗 慢性胃炎波及黏膜全层或呈活动性 出现癌前状态（肠上皮化生、假幽门腺化生、萎缩及不典型增生）Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗-对因治疗 Hp

48、相关性胃炎 方案 1种PPI+1种铋剂+2种抗生素 疗程 7-14天Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗-对因治疗 十二指肠-胃反流 助消化 改善胃动力Department of GastroenterologyDepartment of GastroenterologyThe Fir

49、st Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治 疗-对因治疗 自 身 免 疫 糖皮质激素Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治

50、治 疗疗-对因治疗对因治疗 胃黏膜营养因子缺乏 补充复合维生素 改善胃肠营养Department of GastroenterologyDepartment of GastroenterologyThe First Affiliated Hospital of Chengdu Medical The First Affiliated Hospital of Chengdu Medical CollegeCollege治治 疗疗-对症治疗 抑制或中和胃酸 保护胃黏膜 恶性贫血终生注射维生素B12Department of GastroenterologyDepartment of Gastroe