1、医学1 第十九章第十九章 消化系统疾病消化系统疾病 P278Diseases of the Digestive System医学21组成组成 消化管：口腔消化管：口腔肛门肛门消化腺：涎腺、肝、胰及消化管的粘膜消化腺：涎腺、肝、胰及消化管的粘膜腺体腺体一、一、消化系统解剖组织结构复习消化系统解剖组织结构复习医学3 （1）粘膜层）粘膜层（2）粘膜下层）粘膜下层（3）肌层）肌层（4）浆膜层）浆膜层 2共同的结构特点共同的结构特点医学4第一节第一节 胃炎胃炎 P278一一急性胃炎急性胃炎二二.慢性胃炎慢性胃炎（一）慢性浅表性胃炎（一）慢性浅表性胃炎（二）慢性萎缩性胃炎（二）慢性萎缩性胃炎医学5一、胃炎
2、一、胃炎(gastritis)胃粘膜的炎症性病变胃粘膜的炎症性病变 常见、多常见、多发发 急性胃炎：原因较清楚，嗜中性粒细胞浸润急性胃炎：原因较清楚，嗜中性粒细胞浸润 慢性胃慢性胃炎：自身免疫、胆汁返流、急性迁延，幽门螺杆菌炎：自身免疫、胆汁返流、急性迁延，幽门螺杆菌（一）急性胃炎（一）急性胃炎(acute gastritis)依据病因、胃粘膜依据病因、胃粘膜病变分型病变分型 gastritis）医学6（二）慢性胃炎（二）慢性胃炎(chronic gastritis)病因机制：病因机制：1）幽门螺杆菌（）幽门螺杆菌（HP）慢性感染）慢性感染 2）长期慢性刺激）长期慢性刺激 3）自身免疫）自身免
3、疫 4）胆汁返流）胆汁返流 幽门螺杆菌（幽门螺杆菌（Helicobacter Pylori,HP）粘附胃上皮细胞：产生粘附素粘附胃上皮细胞：产生粘附素 适应高酸环境：分泌尿素酶，水解尿素适应高酸环境：分泌尿素酶，水解尿素氨、氨、CO2 降解表面粘液：细胞毒素相关蛋白，细胞空泡毒素降解表面粘液：细胞毒素相关蛋白，细胞空泡毒素等等空泡变性空泡变性医学7 1.慢性浅表性胃炎慢性浅表性胃炎(chronic superficial gastritis，CSG)最常见、胃镜检出率最常见、胃镜检出率20 40%（1）病变）病变 部位：多累及部位：多累及胃窦部胃窦部、可见于胃体、可见于胃体 肉眼：多灶或弥漫分
4、布、粘膜充血、水肿、或出血、肉眼：多灶或弥漫分布、粘膜充血、水肿、或出血、糜烂糜烂 光镜：固有腺体保持完整粘膜浅层内淋巴细胞、浆细光镜：固有腺体保持完整粘膜浅层内淋巴细胞、浆细胞浸润胞浸润 医学82.慢性萎缩性胃炎慢性萎缩性胃炎(chronic atrophic gastritis,CAG)（1）病变）病变 胃镜：胃镜：a.粘膜变薄、皱襞变平或消失、表面呈细颗粒状粘膜变薄、皱襞变平或消失、表面呈细颗粒状 b.正常胃粘膜橘红色正常胃粘膜橘红色灰白或灰黄灰白或灰黄 c.粘膜下血管分支清晰可见，出血、粘膜下血管分支清晰可见，出血、糜烂糜烂 医学92.慢性萎缩性胃炎慢性萎缩性胃炎(chronic at
5、rophic gastritis,CAG)光镜：光镜：a.粘膜全层内大量淋巴细胞、浆细胞浸润、淋巴滤泡形成粘膜全层内大量淋巴细胞、浆细胞浸润、淋巴滤泡形成 b.胃粘膜固有腺体（胃体腺、幽门腺、贲门腺）萎缩或消失，囊胃粘膜固有腺体（胃体腺、幽门腺、贲门腺）萎缩或消失，囊状扩张状扩张 c.肠上皮化生或假幽门腺化生（粘液分泌细胞化生）灶状或片状，肠上皮化生或假幽门腺化生（粘液分泌细胞化生）灶状或片状，弥漫分布弥漫分布 肠上皮化生肠上皮化生:胃粘膜上皮被肠粘膜上皮取代胃粘膜上皮被肠粘膜上皮取代 完全型化生（小肠型）：吸收细胞、杯状细胞、潘氏细胞完全型化生（小肠型）：吸收细胞、杯状细胞、潘氏细胞 不完全
6、型化生不完全型化生（结肠型化生）：粘液细胞、杯状细胞（结肠型化生）：粘液细胞、杯状细胞与胃癌关系密切与胃癌关系密切 假幽门腺化生：胃底和胃体部的壁细胞和主细胞消失，由分泌粘液的细胞取假幽门腺化生：胃底和胃体部的壁细胞和主细胞消失，由分泌粘液的细胞取代后似幽门腺代后似幽门腺 医学10慢性浅表性胃炎慢性浅表性胃炎（Chronic superficial gastritis）慢性萎缩性胃炎慢性萎缩性胃炎（Chronic atrophic gastritis）肠上皮化生（intestinal metaplasia）肠上皮化生（肠上皮化生（intestinal metaplasia）医学11This i
7、s a more typical acute gastritis with a diffusely hyperemic gastric mucosa.There are many causes for acute gastritis:alcoholism,drugs,infections,etc.医学12第二节第二节 胃溃疡胃溃疡 P280一病因和发病机制一病因和发病机制（一）胃溃疡的发病机制（一）胃溃疡的发病机制（二）十二指肠的发病机制（二）十二指肠的发病机制二二.病理变化病理变化三三.结局和并发症结局和并发症医学13（三）病因及发病机制（三）病因及发病机制 pathogenesis 1.胃
8、黏膜屏障功能减低胃黏膜屏障功能减低 1）迷走神经兴奋性降低）迷走神经兴奋性降低 2）烟、酒、水杨酸盐）烟、酒、水杨酸盐 药物、环境因素、遗传因素、药物、环境因素、遗传因素、胃排空延缓和胆汁返流胃排空延缓和胆汁返流 HP感染、感染、2.胃液消化作用胃液消化作用 胃粘膜屏障破坏胃粘膜屏障破坏胃液自身消化胃液自身消化消消化性溃疡化性溃疡 3.十二指肠溃疡常见原因是胃酸持续性增高十二指肠溃疡常见原因是胃酸持续性增高 正常的胃粘膜防御屏障：正常的胃粘膜防御屏障：粘液粘液-碳酸氢盐屏障碳酸氢盐屏障 粘膜上皮屏障粘膜上皮屏障 丰富的粘膜血流丰富的粘膜血流 医学14 Normal Mucosal defenc
9、e医学15T H E A U T O N O M I C N E R V O U S S Y S T E M H.pylorinormal gastric mucosaH.pylori colonizationnormal gastricmucosacolonized gastricmucosa医学16T H E A U T O N O M I C N E R V O U S S Y S T E M H.pylori is gram-negative spiral flagellated bacterium Produces urease Important in the etiology o
10、f peptic ulcers and gastric cancer Found in:90%patients with duodenal ulceration 70%patients with gastric ulceration 60%patients with gastric cancerHelicobacter pylori医学17Gastritis is often accompanied by infection with Helicobacter pylori.This small curved to spiral rod-shaped bacterium is found in
11、 the surface epithelial mucus of most patients with active gastritis.The rods are seen here with a methylene blue stain.医学18二、二、消化性溃疡病（消化性溃疡病（peptic ulcer disease）（一）概述（一）概述 1.常见病，成人多见，反复发作，慢性经过；胃、十二指常见病，成人多见，反复发作，慢性经过；胃、十二指肠球部，十二指肠肠球部，十二指肠胃胃=70%25%复合性溃疡复合性溃疡5%；与胃；与胃酸、蛋白酶消化作用有关酸、蛋白酶消化作用有关-消化性溃疡消化性溃疡
12、（二）病理变化（胃溃疡）（二）病理变化（胃溃疡）1、肉眼、肉眼（1）部位）部位（2）数目）数目（3）大小）大小（4）形状）形状（5）深度）深度（6）边缘）边缘（7）底部）底部（8）切面）切面（9）周围胃粘膜）周围胃粘膜（10）浆膜面）浆膜面医学19This is the normal appearance of the stomach,which has been opened along the greater curvature.The esophagus is at the left.In the fundus can be seen the lesser curvature.Just
13、beyond the antrum is the pylorus emptying into the first portion of duodenum is at the lower right.The normal appearance of the gastric fundus on upper GI endoscopy is shown below at the left,with the normal duodenal appearance at the right.医学20This is the normal appearance of the gastric antrum ext
14、ending to the pylorus at the right of center.The first portion of the duodenum(duodenal bulb)is at the far right.医学21医学22肉眼：多位于胃小弯、近幽门部；肉眼：多位于胃小弯、近幽门部；溃疡多单个、圆或椭圆，溃疡多单个、圆或椭圆，D2.0cm；边缘整齐，状如刀割，；边缘整齐，状如刀割，底部平坦，深浅不一，可底部平坦，深浅不一，可 达浆膜层；达浆膜层；贲门侧贲门侧-深，潜掘状深，潜掘状 幽门状幽门状-浅，浅，阶梯状；周围粘膜皱壁轮辐状集中。阶梯状；周围粘膜皱壁轮辐状集中。2、镜下（
15、底部）、镜下（底部）（1）Zone of inflammatory exudate（渗出层）（渗出层）（2）Zone of necrotic materials（坏死层）（坏死层）（3）Zone of granulation tissue（肉芽组织层）（肉芽组织层）（4）Zone of collagenous scar（疤痕层）（疤痕层）医学23 增殖性动脉内膜炎（管壁增厚、管腔狭窄）：妨碍组织再生不增殖性动脉内膜炎（管壁增厚、管腔狭窄）：妨碍组织再生不易愈合；防止溃疡底血管出血易愈合；防止溃疡底血管出血 神经细胞、神经纤维变性、神经细胞、神经纤维变性、断裂断裂 球状增生（创伤性神经纤维瘤）球
16、状增生（创伤性神经纤维瘤）疼痛疼痛 溃疡边缘溃疡边缘粘膜肌层与肌层粘连粘膜肌层与肌层粘连诊断溃疡病的重要依据诊断溃疡病的重要依据十二指肠溃疡：球部多见，前壁或后壁，较胃溃疡小、浅，十二指肠溃疡：球部多见，前壁或后壁，较胃溃疡小、浅，D1.0cm 医学24医学25This is the normal appearance of the gastric fundal mucosa,with short pits lined by pale columnar mucus cells leading into long glands which contain bright pink parietal
17、 cells that secrete hydrochloric acid.医学26Microscopically,the ulcer here is sharply demarcated,with normal gastric mucosa on the left falling away into a deep ulcer whose base contains infamed,necrotic debris.An arterial branch at the ulcer base is eroded and bleeding.医学27The mucosa at the upper rig
18、ht merges into the ulcer at the left which is eroding through the mucosa.Ulcers will penetrate over time if they do not heal.Penetration leads to pain.If the ulcer penetrates through the muscularis and through adventitia,then the ulcer is said to perforate and leads to an acute abdomen.An abdominal
19、radiograph may demonstrate free air with a perforation.医学28The ulcer at the right is penetrating through the muscularis and approaching an artery.Erosion of the ulcer into the artery will lead to another major complication of ulcers-hemorrhage.This hemorrhage can be life threatening.Chronic blood lo
20、ss may lead to an iron deficiency anemia.医学29Duodenal UlcerGastric Ulcer医学30医学31医学32（四）结局及合并症（四）结局及合并症（fate and complications）1、愈合、愈合 healing 肉芽组织增生肉芽组织增生-机化机化-瘢痕瘢痕 2、出血、出血 hemorrhage 1/3，最多见；小血管，最多见；小血管 潜血、潜血、黑便；大血管黑便；大血管 呕血、失血性休克呕血、失血性休克3、穿孔、穿孔 perforation 5%，十二指肠易发生（壁薄），十二指肠易发生（壁薄），前壁多见前壁多见-腹膜炎腹膜
21、炎（急性弥漫性）后壁溃疡如穿透较慢，与邻（急性弥漫性）后壁溃疡如穿透较慢，与邻近器官粘连近器官粘连穿透性溃疡穿透性溃疡局限性腹膜炎局限性腹膜炎 4、幽门狭窄、幽门狭窄 pyloric stenosis 2%3%瘢痕收缩瘢痕收缩 胃扩张、胃扩张、呕吐呕吐 5、癌变、癌变 malignant transformation 1%胃溃疡约胃溃疡约1%，十二指肠溃疡几乎不癌变十二指肠溃疡几乎不癌变医学335.5.临床病理联系：临床病理联系：上腹部长期性、上腹部长期性、周期性和节律性疼痛；钝痛、烧灼痛或饥周期性和节律性疼痛；钝痛、烧灼痛或饥饿样痛；剧痛穿孔饿样痛；剧痛穿孔 十二指肠溃十二指肠溃疡空腹痛、饥
22、饿痛、夜间痛疡空腹痛、饥饿痛、夜间痛 胃胃溃疡进食后痛溃疡进食后痛医学34医学35医学36In the endoscopic views,the normal appearance of the pylorus is seen at the left,with the first portion of the duodenum at the right.医学37Seen above are gastric ulcers of small,medium,and large size on upper endoscopy.All gastric ulcers are biopsied,since
23、gross inspection alone cannot determine whether a malignancy is present.Smaller,more sharply demarcated ulcers are more likely to be benign.医学38医学39Here is a much larger 3 x 4 cm gastric ulcer that led to the resection of the stomach shown here.This ulcer is much deeper with more irregular margins.C
24、omplications of gastric ulcers(either benign or malignant)include pain,bleeding,perforation,and obstruction.医学40The strongest association with Helicobacter pylori is with duodenal peptic ulceration-over 85%of duodenal ulcers.Seen here is a penetrating acute ulceration in the duodenum just beyond the
25、 pylorus.医学41An acute duodenal ulcer is seen in two views on upper endoscopy in the panels below.医学42医学43医学441 1 了解胃炎的分类，熟悉慢性胃炎的类型及病理特点。了解胃炎的分类，熟悉慢性胃炎的类型及病理特点。2 2 掌握慢性消化性溃疡的发病机制，病变特点，临床病掌握慢性消化性溃疡的发病机制，病变特点，临床病理联系。理联系。3 3 熟悉病毒性肝炎的病因、掌握各型肝炎的病理变化及熟悉病毒性肝炎的病因、掌握各型肝炎的病理变化及转归。转归。4 4 掌握肝硬变的发病机制、类型、形态特点及临床病理掌握肝硬变的发病机制、类型、形态特点及临床病理联系。联系。5 5 了解食道癌、胃癌、原发性肝癌的病因发病机制、熟悉了解食道癌、胃癌、原发性肝癌的病因发病机制、熟悉病理形态特点及其与临床联系。病理形态特点及其与临床联系。目的要求目的要求
