Rugge M, Genta RM, Malfertheiner P, et al. Gut 2024;73;407–441.
"위염"은 흔하게 언급하고 내시경 검사에서 관찰되는 병변이지만, 공통된 정의에 맞게 사용하지 못하고 위암 등과 같은 질환들에 가려져 있어 현재 까지도 모호하게 불려지는 질환입니다. 약 100년 전부터 시작된 위염에 대한 관심은 약 40년 전 H. pylori 발견을 계기로 새로운 전환점을 맞았고, 이후 1990년과 1994년 Sydney classification과 2015년 Kyoto consensus 등을 거치면서 H. pylori와 함께 조금씩 정의와 분류를 체계화 하려는 노력이 이루어 지고 있습니다.
이번 update는 2022년 약 8개월에 걸쳐서, Africa, North and South America, Asia, Australia 그리고 Europe 의 전문가들이 회의를 통해 "위염"에 대해 다음과 같이 총 8가지 항목으로 나누어 consensus를 정리한 내용입니다.
1. Definitions and classification issues in the gastritis spectrum
2. The spectrum of H. pylori gastritis
3. Key diagnostics in H. pylori gastritis
4. H. pylori gastritis: clinical outcome
5. Autoimmune gastritis (AIG)
6. Low-prevalence gastritis
7. Gastritis and gastric microbiota
8. Epidemiology of gastritis and related preneoplastic and neoplastic lesions
<1. Definitions and classification issues in the gastritis spectrum>
Gastritis defines a spectrum of conditions characterised by histologically documented inflammation of the gastric mucosa. Mononuclear cells (eg, lymphocytes, histiocytes, plasma cells) and small numbers of eosinophils, but not polymorphonuclear neutrophils (PMNs), reside in the normal gastric lamina propria. This required distinguishing between a mononuclear population ‘within normal limits’ and low-grade inflammatory lesions
Gastritis should be differentiated from gastropathy, which identifies mucosal abnormalities (eg, foveolar hyperplasia, muscularis mucosae hyperplasia) with a minimal or no inflammatory component (ie, reactive gastropathy resulting from duodenogastric reflux, portal hypertensive gastropathy and gastric antral vascular ectasia) (see section 2.1.3). From a practical standpoint, however, the two conditions frequently overlap. In routine histological assessment, ‘gastritis’ defines low-grade to high-grade inflammatory diseases.
The definitions of gastritis are crucially influenced by gastric anatomy, physiology and pathophysiology. The stomach’s compartmentalisation, as established in the embryo and retained in the adult, results in a single visceral sac consisting of two anatomically and functionally different sections (oxyntic corpus/ fundus vs mucosecreting antral/pyloric).
Aetiology, clinical course, endoscopic and histological phenotypes specifically identify different gastritis subtypes. The Kyoto classification classifies gastritis according to its environmental or host-related aetiological agent; the clinical course distinguishes acute (ie, self-limiting) versus chronic (ie, long-standing, non-self-limiting) inflammatory diseases; gastroscopy and histology identify gastritis subtypes according to their gross or microscopic phenotypes.
"위 점막의 임상병리학적 정의가 임상적 우선순위이며, 일반적인 용어로써 "위염"은 오해를 불러 일으키고 잘못된 관리 전력의 위험이 있으므로 사용하지 않는 것이 좋다"
<Comment>
'Gastritis' 용어는 가끔 일반인이나 의사들이 dyspeptic symptoms 의 동의어로 사용하는 경우가 있습니다. Making such unqualified diagnoses of gastritis 는 부정확한 임상적 추정을 하게 하거나, 부적절한 치료 전략 (eg, long-term proton pump inhibitor (PPI) treatment) 혹은, 불필요한 내시경검사 등을 초래할 수 있습니다.
정상 gastroscopy를 정의하기는 어렵지만, Regular arrangement of collecting venules (RAC)는 >90% positive predictive value for normal gastric oxyntic mucosa and reliably excludes H. pylori infection을 의미합니다 (Figure. 1).
Figure 1. Gastroscopy within normal limits. White-light gastroscopy: antral (A), angularis and corpus mucosa (B) within normal limits. Normal antrum (C) and corpus mucosa (D) in narrow-band imaging.
Histological하게 보면, 위 점막은 크게 2개의 main types mucosa (oxyntic & mucosecreting pyloric)으로 나눌 수 있지만, EG junction에서 distal 방향으로의 'cardia phenotype: foveolar epithelium with mucous glands and no parietal cells'의 third mucosal type이 있습니다.
The interface between oxyntic and antral mucosa consists of a ‘transitional phenotype’, with intermingling oxyntic and mucosecreting glands (see section 2.5.1). The presence of mucosecreting glands proximal to the incisura angularis raises the possibility of metaplastic pseudopyloric transformation (see section 2.5.3) of the native oxyntic mucosa extending distally beyond the incisura angularis
정상 lamina propria에는 lymphocytes는 매우 드물고 plasma cells과 eosinophils도 rare하며 neutrophils은 관찰되지 않습니다 (Figure 2).
Figure 2. Gastric mucosa within normal limits. (A) The oxyntic mucosa covers two-thirds of the stomach (cranial portion). In sections stained with H&E, glandular pits are lined by surface mucous cells and, more in depth, by mucous neck cells of the proliferative zone. Deeper into the foveolae (commonly referred to as pits), closely packed tubular glands include parietal and peptic (chief) cells. Neuroendocrine cells (ie, enterochromaffin-like cells) are scattered through the oxyntic epithelium, primarily located in the deeper third of the glandular units. The deeper part of the oxyntic glands reaches the most superficial layer of the muscularis mucosae. Rare lymphocytes, plasma cells and eosinophils are restricted to the lamina propria of the interfoveolar zone; granulocytes are absent (H&E, original magnification 20×). (B) The distal stomach is lined by antral mucosecreting mucosa. The foveolae of the mucosecreting compound tubular glands cover approximately half the mucosa thickness; the mucus-secreting coils occupy the basal half of the mucosa. Each foveola dichotomises in two tubular branches; each branch further divides into four to five glandular coils involved in the mucous secretion. Coils are embedded in the loose connective tissue of the lamina propria, which is populated by scattered lympho-histiocytes, plasmacytes and rare eosinophils. Polymorphonuclear granulocytes are absent (H&E, original magnification 20×).
결국, Mucosal structure (including inflammatory infiltrates, lymphoid follicles, atrophy, intestinal or pseudopyloric metaplasia, detectable organisms, hyperplastic or neoplastic changes)의 변화에 대한 조직학적 증거가 없는 경우를 ‘gastric mucosa within normal limits’ 라고 해야 합니다.
Table 1. Phenotypes of non-neoplastic pathology in gastric mucosa: definitions
* In clinical practice, the definition of ‘atrophic gastritis’ also covers a precancerous condition, irrespective of coexisting inflammation. AIG, autoimmune gastritis; ECL, enterochromaffin-like; IM, intestinal metaplasia; OLGA/OLGIM, operating link for gastritis assessment/operating link for gastric IM; PMN, polymorphonuclear granulocyte (refers specifically to 'neutrophilic granulocytes'); PPI, proton pump inhibitor; pPM, pseudopyloric metaplasia.
"급성 위염은 임상적으로 비전염성 혹은 전염성 물질로 인해 발생한 위 점막의 단기 지속적(일반적으로 한정된 기간을 가지는)인 증상을 갖는 염증성 변화의 광범위한 범위로 정의한다"
<Comment>
Kyoto classification에 따르면, 소위 "acute gastritis"에 대한 원인들에는 비 전염성 및 전염성 물질을 포함하고 있습니다 (Table 2).
Table 2. Aetiology of gastritis
임상 증상은 aetiology에 따라 다양하게 나타날 수 있습니다. 오목 가슴 통증이 다양한 강도와 빈도로 나타날 수 있고 오심, 구토 및 식후 불편감 등이 동반될 수 있습니다. 발열, 무기력감, 식은땀 및 저혈압과 같은 일반적 증상도 있을 수 있습니다. 출혈은 드물게 petechiae, diffuse hemorrhagic gastritis, erosions 으로 부터 발생할 수도 있습니다.
내시경 소견은 hyperaemia, oedema, friable mucosa, mucosal weals, erosions, gastric distension, bleeding, 드물게 phlegmon이나 ulcers 등도 있을 수 있습니다.
조직 검사는 aetiological clues를 제공할 수 있지만, 아직 특정한 biopsy protocol은 없으며, 염증 세포집단의 침착 정도를 기본으로 acute (short-lasting, 보통 self-limiting)와 chronic (long-standing) gastritis를 구분하는 전통적인 조직학적 구분은 유용하지 않습니다. Lymphocytes (chronic inflammation과 연관성이 있는)가 우세하지만 polymorphonuclear granulocytes (PMN, 전형적으로 'acute' inflammation과 연관성이 있는)도 'long-staging' ('chronic' 이라고 임상적으로 정의하는) inflammatory gastric diseases (eg. H. pylori gastritis)에서 풍부하게 발견되기 때문입니다.
Different histological patterns according to the aetiology are summarised in table 3.
Table 3. Acute gastritis: basic histological patterns.
"만성 위염은 임상적으로 위 점막의 장기간 지속되는 염증으로 정의한다. 만성 위염은 근본적인 원인이 지속적으로 존재하는 경우 평생동안 지속되며, 가장 흔한 병인체는 'H. pylori' 이다"
<Comment>
만성 위염은 위 점막의 long-lasting (일반적으로 non-selflimiting) inflammation으로 정의 됩니다. Long-lasting gastritis는 약한 dyspeptic symptoms과 연관성이 있을 수 있지만, 보통 asymptomatic 합니다. 가장 흔한 chronic (non-self limiting) gastritis 의 원인은 H. pylori 이지만, 다른 원인으로 비 감염성 (host-related systemic conditions)인 autoimmune gastritis (AIG)나 immune-mediated contion (eg, Crohn's disease)도 있습니다. 또한 Sydney system에서 'special forms (여기서는 host related)'으로 분류된 colllagenous, eosinophilic, lymphocytic gastritis도 long-standing immune-mediated gastritis라고 할 수 있습니다 (table 2; section 2.1.2).
* Histological features: gastric mucosa의 현저한 inflammation으로 정상적인 glandular structures의 loss로 인한 mucosal atrophy와 연관성이 있습니다. 원인에 따라서 2개의 mucosal compartments에 대한 inflammation과 atrophy 정도에 차이가 있을 수 있습니다.
* Non-atrophic gastritis: the inflammatory lesions may evenly involve both gastric compartments or predominate in either the antral or corpus/fundus mucosa.
* Atrophic gastritis: Mucosal atrophy is defined as the loss of native glands with or without metaplastic changes (intestinal and pseudopyloric metaplasia).
- Limited to the mucosecreting antrum
- Restirced to the oxyntic corpus/fundus
- Involving both compartments: multifocal atrophic gastrits or atrophic pangastritis
The term ‘pangastritis’ should be exclusively (전적으로) used when referring to widespread atrophy of gastric mucosa, coexisting with inflammatory infiltrate (antrum과 corpus 모두) (table 1, section 2.3.2; figure 3).
Figure 3. Atrophy spreading throughout gastric mucosa according to the natural history of different aetiological models. Stomach opens along the greater curvature. The native mucosecreting (antral) compartment is depicted in light blue; the oxyntic (corpus/fundic) mucosa is green; the oxyntic–pyloric border is ideally between light blue and green compartments. Atrophic transformation is depicted in light orange. Three aetiopathogenetic models are shown (from top to bottom): (1) atrophy spreading in Helicobacter pylori (Hp) gastritis; (2) mucosal atrophy in autoimmune gastritis (AIG); (3) mucosal atrophy in Hp infection coexisting with AIG. In long-standing Hp gastritis, the earliest atrophic lesions involve the mucosecreting antrum (light blue changed into light orange) and they steadily spread cranially involving the oxyntic mucosa: closed (C1–C2–C3) and open (O1–O2–O3) patterns of Kimura and Takemoto atrophic gastritis are associated with the progressive cranialisation of the ‘atrophic border’ (see also figure 1). The concurrent atrophic involvement of antral and oxyntic mucosa may eventually result in pan-atrophic gastritis. In AIG, the atrophic lesions are restricted to the oxyntic compartment (original green changed into light orange/green). The progression of atrophy involves extensively the cranial stomach, sparing the mucosecreting compartment. Even in the most advanced atrophy, because of the unaffected mucosecreting antrum, the definition of pangastritis is semantically inappropriate (ie, the O3 pattern should require antral atrophy; see section 2.5.5). When Hp infection coexists with AIG (which targets the oxyntic mucosa), atrophic transformation may extensively involve both mucosal compartments, resulting in pan-atrophic disease.
엄격한 의미에서, "Atrophic gastritis"와 "Gastric atrophy"는 의미가 다릅니다.
(Progression의 risk도 다르고, clinical approach도 다르게 해야 함)
* Atrophic gastritis: PMN가 풍부한 염증성 세포가 포함된 active H. pylori infection에 의한 결과로 발생
* Gastric atrophy: H. pylori eradication된 이후 혹은 'spontaneous'하게 사라진 뒤 염증성 변화가 거의 없는 상태 (table 1; sections 2.4.3 and 2.4.4).
이 둘을 구분하는 것은 특히, inflammation이 patient's management를 달리해야 하는 clinical trial에서 임상적 해석을 달리해야 합니다. 일반적으로 eradication 이후 조직을 살펴보면, PMN이 줄어드는 것이 lymphocyte의 infiltration 보다 먼저 나타나며 atrophic change의 호전은 early atrophic disease에서만 가능하기 때문입니다.
병변의 범위와 이러한 병변의 원인과 경과 사이의 관계가 매우 중요하기 때문에, 내시경 및 병리학적 repots에서는 염증성 병변과 위축성 병변의 범위를 분명하게 언급해야 합니다.
모든 H. pylori-infected subjects는 chronic active gastritis를 가지고 있다고 할 수 있고, non-invasive testing (serology, stool or breath tests; see section 2.2.2)를 non-invasive한 diagnostic markers의 대체 방법으로 사용할 수 있습니다. 또한, atrophy는 non-invasive하게 serum gastrin, pepsinogen (Pg) I, II (Pg I/II ratio 포함)를 이용하여 평가 할 수 있습니다.
위 점막의 형태는 gatroscopy를 이용하여 적절하게 평가할 수 있는데, high-definition gastroscopy (IEE, Magnification 포함)에서는 gastritis에 대한 다양한 모양들(mucosal nodularity, oedema, blurring of the appearance of connecting venules, enlarged folds)을 관찰 할 수 있습니다. Endoscopic evidence of Atrophy에 대한 내시경적 evidence는 disappearance of gastric folds, enhancement of the mucosal vasculature 등이 있으며, Intestinal metaplasia (IM)는 grey-white patches로 나타나고 narrow-band imaging (NBI)를 이용하면 light-blue lines 또는, 소위 light-blue crests를 관찰 할 수 있습니다.
Atrophy유무를 떠나서 chronic gastritis는 underlying aetiology를 해결함으로써 관리하는 것입니다.
"전암상태는 종양 발생의 위험이 증가 된 상태로 정의한다. 위염은 병인과 단계와 같은 요인에 따라 위험도의 차이를 가지고 있는 전암 상태이다."
<Comment>
Preneoplastic (synonym: precancerous) condition은 악성종양으로 진행할 수 있는 위험성을 가진 종양이 아닌 질환들(non-neoplastic diseases)을 의미합니다. 이러한 정의에서는 preneoplastic 'conditions(상태)'와 'lesions(병변)'은 구분하여 사용해야 합니다. Lesions은 악성종양의 조직발생을 포함한 anatomical background(s)로써(eg, epithelial abnormalities (intra-epithelial neoplasia (IEN)), invasive adenocarcinoma나 enterochromaffin-like (ECL) gastric cell proliferation으로 인해 잠재적으로 type 1 neuroendocrine tumours (type 1 NETs)로 진행하는 것을 의미합니다.
Preneoplastic conditions
* Hos-related conditions: genetic abnormalities (synromic cancers), immune-mediated mechanisms으로 생긴 gatric diseases
* Environmental conditions: infectious diseases (eg, H. pylori, EBV(see section 2.6.5)), medical or surgical interventions (eg, gastric stumps)
(Long-standing non-self-limiting H. pylori gastritis (특히, atrophy가 있는) 가장 흔한 environmental preneoplastic condition)
<Abstract>
At the end of the last century, a far-sighted ’working party’ held in Sydney, Australia addressed the clinicopathological issues related to gastric inflammatory diseases. A few years later, an international conference held in Houston, Texas, USA critically updated the seminal Sydney classification. In line with these initiatives, Kyoto Global Consensus Report, flanked by the Maastricht-Florence conferences, added new clinical evidence to the gastritis clinicopathological puzzle. The most relevant topics related to the gastric inflammatory diseases have been addressed by the Real-world Gastritis Initiative (RE.GA.IN.), from disease definitions to the clinical diagnosis and prognosis. This paper reports the conclusions of the RE.GA.IN. consensus process, which culminated in Venice in November 2022 after more than 8months of intense global scientific deliberations. A forum of gastritis scholars from five continents participated in the multidisciplinary RE.GA.IN. consensus. After lively debates on the most controversial aspects of the gastritis spectrum, the RE.GA.IN. Faculty amalgamated complementary knowledge to distil patient-centred, evidence-based statements to assist health professionals in their real-world clinical practice. The sections of this report focus on: the epidemiology of gastritis; Helicobacter pylori as dominant aetiology of environmental gastritis and as the most important determinant of the gastric oncogenetic field; the evolving knowledge on gastric autoimmunity; the clinicopathological relevance of gastric microbiota; the new diagnostic horizons of endoscopy; and the clinical priority of histologically reporting gastritis in terms of staging. The ultimate goal of RE.GA.IN. was and remains the promotion of further improvement in the clinical management of patients with gastritis.
Rugge M, Genta RM, Malfertheiner P, et al. Gut 2024;73;407–441.
"위염"은 흔하게 언급하고 내시경 검사에서 관찰되는 병변이지만, 공통된 정의에 맞게 사용하지 못하고 위암 등과 같은 질환들에 가려져 있어 현재 까지도 모호하게 불려지는 질환입니다. 약 100년 전부터 시작된 위염에 대한 관심은 약 40년 전 H. pylori 발견을 계기로 새로운 전환점을 맞았고, 이후 1990년과 1994년 Sydney classification과 2015년 Kyoto consensus 등을 거치면서 H. pylori와 함께 조금씩 정의와 분류를 체계화 하려는 노력이 이루어 지고 있습니다.
이번 update는 2022년 약 8개월에 걸쳐서, Africa, North and South America, Asia, Australia 그리고 Europe 의 전문가들이 회의를 통해 "위염"에 대해 다음과 같이 총 8가지 항목으로 나누어 consensus를 정리한 내용입니다.
1. Definitions and classification issues in the gastritis spectrum
2. The spectrum of H. pylori gastritis
3. Key diagnostics in H. pylori gastritis
4. H. pylori gastritis: clinical outcome
5. Autoimmune gastritis (AIG)
6. Low-prevalence gastritis
7. Gastritis and gastric microbiota
8. Epidemiology of gastritis and related preneoplastic and neoplastic lesions
<1. Definitions and classification issues in the gastritis spectrum>
Gastritis defines a spectrum of conditions characterised by histologically documented inflammation of the gastric mucosa. Mononuclear cells (eg, lymphocytes, histiocytes, plasma cells) and small numbers of eosinophils, but not polymorphonuclear neutrophils (PMNs), reside in the normal gastric lamina propria. This required distinguishing between a mononuclear population ‘within normal limits’ and low-grade inflammatory lesions
Gastritis should be differentiated from gastropathy, which identifies mucosal abnormalities (eg, foveolar hyperplasia, muscularis mucosae hyperplasia) with a minimal or no inflammatory component (ie, reactive gastropathy resulting from duodenogastric reflux, portal hypertensive gastropathy and gastric antral vascular ectasia) (see section 2.1.3). From a practical standpoint, however, the two conditions frequently overlap. In routine histological assessment, ‘gastritis’ defines low-grade to high-grade inflammatory diseases.
The definitions of gastritis are crucially influenced by gastric anatomy, physiology and pathophysiology. The stomach’s compartmentalisation, as established in the embryo and retained in the adult, results in a single visceral sac consisting of two anatomically and functionally different sections (oxyntic corpus/ fundus vs mucosecreting antral/pyloric).
Aetiology, clinical course, endoscopic and histological phenotypes specifically identify different gastritis subtypes. The Kyoto classification classifies gastritis according to its environmental or host-related aetiological agent; the clinical course distinguishes acute (ie, self-limiting) versus chronic (ie, long-standing, non-self-limiting) inflammatory diseases; gastroscopy and histology identify gastritis subtypes according to their gross or microscopic phenotypes.
"위 점막의 임상병리학적 정의가 임상적 우선순위이며, 일반적인 용어로써 "위염"은 오해를 불러 일으키고 잘못된 관리 전력의 위험이 있으므로 사용하지 않는 것이 좋다"
<Comment>
'Gastritis' 용어는 가끔 일반인이나 의사들이 dyspeptic symptoms 의 동의어로 사용하는 경우가 있습니다. Making such unqualified diagnoses of gastritis 는 부정확한 임상적 추정을 하게 하거나, 부적절한 치료 전략 (eg, long-term proton pump inhibitor (PPI) treatment) 혹은, 불필요한 내시경검사 등을 초래할 수 있습니다.
정상 gastroscopy를 정의하기는 어렵지만, Regular arrangement of collecting venules (RAC)는 >90% positive predictive value for normal gastric oxyntic mucosa and reliably excludes H. pylori infection을 의미합니다 (Figure. 1).
Figure 1. Gastroscopy within normal limits. White-light gastroscopy: antral (A), angularis and corpus mucosa (B) within normal limits. Normal antrum (C) and corpus mucosa (D) in narrow-band imaging.
Histological하게 보면, 위 점막은 크게 2개의 main types mucosa (oxyntic & mucosecreting pyloric)으로 나눌 수 있지만, EG junction에서 distal 방향으로의 'cardia phenotype: foveolar epithelium with mucous glands and no parietal cells'의 third mucosal type이 있습니다.
The interface between oxyntic and antral mucosa consists of a ‘transitional phenotype’, with intermingling oxyntic and mucosecreting glands (see section 2.5.1). The presence of mucosecreting glands proximal to the incisura angularis raises the possibility of metaplastic pseudopyloric transformation (see section 2.5.3) of the native oxyntic mucosa extending distally beyond the incisura angularis
정상 lamina propria에는 lymphocytes는 매우 드물고 plasma cells과 eosinophils도 rare하며 neutrophils은 관찰되지 않습니다 (Figure 2).
Figure 2. Gastric mucosa within normal limits. (A) The oxyntic mucosa covers two-thirds of the stomach (cranial portion). In sections stained with H&E, glandular pits are lined by surface mucous cells and, more in depth, by mucous neck cells of the proliferative zone. Deeper into the foveolae (commonly referred to as pits), closely packed tubular glands include parietal and peptic (chief) cells. Neuroendocrine cells (ie, enterochromaffin-like cells) are scattered through the oxyntic epithelium, primarily located in the deeper third of the glandular units. The deeper part of the oxyntic glands reaches the most superficial layer of the muscularis mucosae. Rare lymphocytes, plasma cells and eosinophils are restricted to the lamina propria of the interfoveolar zone; granulocytes are absent (H&E, original magnification 20×). (B) The distal stomach is lined by antral mucosecreting mucosa. The foveolae of the mucosecreting compound tubular glands cover approximately half the mucosa thickness; the mucus-secreting coils occupy the basal half of the mucosa. Each foveola dichotomises in two tubular branches; each branch further divides into four to five glandular coils involved in the mucous secretion. Coils are embedded in the loose connective tissue of the lamina propria, which is populated by scattered lympho-histiocytes, plasmacytes and rare eosinophils. Polymorphonuclear granulocytes are absent (H&E, original magnification 20×).
결국, Mucosal structure (including inflammatory infiltrates, lymphoid follicles, atrophy, intestinal or pseudopyloric metaplasia, detectable organisms, hyperplastic or neoplastic changes)의 변화에 대한 조직학적 증거가 없는 경우를 ‘gastric mucosa within normal limits’ 라고 해야 합니다.
Table 1. Phenotypes of non-neoplastic pathology in gastric mucosa: definitions
"급성 위염은 임상적으로 비전염성 혹은 전염성 물질로 인해 발생한 위 점막의 단기 지속적(일반적으로 한정된 기간을 가지는)인 증상을 갖는 염증성 변화의 광범위한 범위로 정의한다"
<Comment>
Kyoto classification에 따르면, 소위 "acute gastritis"에 대한 원인들에는 비 전염성 및 전염성 물질을 포함하고 있습니다 (Table 2).
Table 2. Aetiology of gastritis
임상 증상은 aetiology에 따라 다양하게 나타날 수 있습니다. 오목 가슴 통증이 다양한 강도와 빈도로 나타날 수 있고 오심, 구토 및 식후 불편감 등이 동반될 수 있습니다. 발열, 무기력감, 식은땀 및 저혈압과 같은 일반적 증상도 있을 수 있습니다. 출혈은 드물게 petechiae, diffuse hemorrhagic gastritis, erosions 으로 부터 발생할 수도 있습니다.
내시경 소견은 hyperaemia, oedema, friable mucosa, mucosal weals, erosions, gastric distension, bleeding, 드물게 phlegmon이나 ulcers 등도 있을 수 있습니다.
조직 검사는 aetiological clues를 제공할 수 있지만, 아직 특정한 biopsy protocol은 없으며, 염증 세포집단의 침착 정도를 기본으로 acute (short-lasting, 보통 self-limiting)와 chronic (long-standing) gastritis를 구분하는 전통적인 조직학적 구분은 유용하지 않습니다. Lymphocytes (chronic inflammation과 연관성이 있는)가 우세하지만 polymorphonuclear granulocytes (PMN, 전형적으로 'acute' inflammation과 연관성이 있는)도 'long-staging' ('chronic' 이라고 임상적으로 정의하는) inflammatory gastric diseases (eg. H. pylori gastritis)에서 풍부하게 발견되기 때문입니다.
Different histological patterns according to the aetiology are summarised in table 3.
Table 3. Acute gastritis: basic histological patterns.
"만성 위염은 임상적으로 위 점막의 장기간 지속되는 염증으로 정의한다. 만성 위염은 근본적인 원인이 지속적으로 존재하는 경우 평생동안 지속되며, 가장 흔한 병인체는 'H. pylori' 이다"
<Comment>
만성 위염은 위 점막의 long-lasting (일반적으로 non-selflimiting) inflammation으로 정의 됩니다. Long-lasting gastritis는 약한 dyspeptic symptoms과 연관성이 있을 수 있지만, 보통 asymptomatic 합니다. 가장 흔한 chronic (non-self limiting) gastritis 의 원인은 H. pylori 이지만, 다른 원인으로 비 감염성 (host-related systemic conditions)인 autoimmune gastritis (AIG)나 immune-mediated contion (eg, Crohn's disease)도 있습니다. 또한 Sydney system에서 'special forms (여기서는 host related)'으로 분류된 colllagenous, eosinophilic, lymphocytic gastritis도 long-standing immune-mediated gastritis라고 할 수 있습니다 (table 2; section 2.1.2).
* Histological features: gastric mucosa의 현저한 inflammation으로 정상적인 glandular structures의 loss로 인한 mucosal atrophy와 연관성이 있습니다. 원인에 따라서 2개의 mucosal compartments에 대한 inflammation과 atrophy 정도에 차이가 있을 수 있습니다.
* Non-atrophic gastritis: the inflammatory lesions may evenly involve both gastric compartments or predominate in either the antral or corpus/fundus mucosa.
* Atrophic gastritis: Mucosal atrophy is defined as the loss of native glands with or without metaplastic changes (intestinal and pseudopyloric metaplasia).
- Limited to the mucosecreting antrum
- Restirced to the oxyntic corpus/fundus
- Involving both compartments: multifocal atrophic gastrits or atrophic pangastritis
The term ‘pangastritis’ should be exclusively (전적으로) used when referring to widespread atrophy of gastric mucosa, coexisting with inflammatory infiltrate (antrum과 corpus 모두) (table 1, section 2.3.2; figure 3).
Figure 3. Atrophy spreading throughout gastric mucosa according to the natural history of different aetiological models. Stomach opens along the greater curvature. The native mucosecreting (antral) compartment is depicted in light blue; the oxyntic (corpus/fundic) mucosa is green; the oxyntic–pyloric border is ideally between light blue and green compartments. Atrophic transformation is depicted in light orange. Three aetiopathogenetic models are shown (from top to bottom): (1) atrophy spreading in Helicobacter pylori (Hp) gastritis; (2) mucosal atrophy in autoimmune gastritis (AIG); (3) mucosal atrophy in Hp infection coexisting with AIG. In long-standing Hp gastritis, the earliest atrophic lesions involve the mucosecreting antrum (light blue changed into light orange) and they steadily spread cranially involving the oxyntic mucosa: closed (C1–C2–C3) and open (O1–O2–O3) patterns of Kimura and Takemoto atrophic gastritis are associated with the progressive cranialisation of the ‘atrophic border’ (see also figure 1). The concurrent atrophic involvement of antral and oxyntic mucosa may eventually result in pan-atrophic gastritis. In AIG, the atrophic lesions are restricted to the oxyntic compartment (original green changed into light orange/green). The progression of atrophy involves extensively the cranial stomach, sparing the mucosecreting compartment. Even in the most advanced atrophy, because of the unaffected mucosecreting antrum, the definition of pangastritis is semantically inappropriate (ie, the O3 pattern should require antral atrophy; see section 2.5.5). When Hp infection coexists with AIG (which targets the oxyntic mucosa), atrophic transformation may extensively involve both mucosal compartments, resulting in pan-atrophic disease.
(Progression의 risk도 다르고, clinical approach도 다르게 해야 함)
* Atrophic gastritis: PMN가 풍부한 염증성 세포가 포함된 active H. pylori infection에 의한 결과로 발생
* Gastric atrophy: H. pylori eradication된 이후 혹은 'spontaneous'하게 사라진 뒤 염증성 변화가 거의 없는 상태 (table 1; sections 2.4.3 and 2.4.4).
이 둘을 구분하는 것은 특히, inflammation이 patient's management를 달리해야 하는 clinical trial에서 임상적 해석을 달리해야 합니다. 일반적으로 eradication 이후 조직을 살펴보면, PMN이 줄어드는 것이 lymphocyte의 infiltration 보다 먼저 나타나며 atrophic change의 호전은 early atrophic disease에서만 가능하기 때문입니다.
병변의 범위와 이러한 병변의 원인과 경과 사이의 관계가 매우 중요하기 때문에, 내시경 및 병리학적 repots에서는 염증성 병변과 위축성 병변의 범위를 분명하게 언급해야 합니다.
모든 H. pylori-infected subjects는 chronic active gastritis를 가지고 있다고 할 수 있고, non-invasive testing (serology, stool or breath tests; see section 2.2.2)를 non-invasive한 diagnostic markers의 대체 방법으로 사용할 수 있습니다. 또한, atrophy는 non-invasive하게 serum gastrin, pepsinogen (Pg) I, II (Pg I/II ratio 포함)를 이용하여 평가 할 수 있습니다.
위 점막의 형태는 gatroscopy를 이용하여 적절하게 평가할 수 있는데, high-definition gastroscopy (IEE, Magnification 포함)에서는 gastritis에 대한 다양한 모양들(mucosal nodularity, oedema, blurring of the appearance of connecting venules, enlarged folds)을 관찰 할 수 있습니다. Endoscopic evidence of Atrophy에 대한 내시경적 evidence는 disappearance of gastric folds, enhancement of the mucosal vasculature 등이 있으며, Intestinal metaplasia (IM)는 grey-white patches로 나타나고 narrow-band imaging (NBI)를 이용하면 light-blue lines 또는, 소위 light-blue crests를 관찰 할 수 있습니다.
Atrophy유무를 떠나서 chronic gastritis는 underlying aetiology를 해결함으로써 관리하는 것입니다.
"전암상태는 종양 발생의 위험이 증가 된 상태로 정의한다. 위염은 병인과 단계와 같은 요인에 따라 위험도의 차이를 가지고 있는 전암 상태이다."
<Comment>
Preneoplastic (synonym: precancerous) condition은 악성종양으로 진행할 수 있는 위험성을 가진 종양이 아닌 질환들(non-neoplastic diseases)을 의미합니다. 이러한 정의에서는 preneoplastic 'conditions(상태)'와 'lesions(병변)'은 구분하여 사용해야 합니다. Lesions은 악성종양의 조직발생을 포함한 anatomical background(s)로써(eg, epithelial abnormalities (intra-epithelial neoplasia (IEN)), invasive adenocarcinoma나 enterochromaffin-like (ECL) gastric cell proliferation으로 인해 잠재적으로 type 1 neuroendocrine tumours (type 1 NETs)로 진행하는 것을 의미합니다.
Preneoplastic conditions
* Hos-related conditions: genetic abnormalities (synromic cancers), immune-mediated mechanisms으로 생긴 gatric diseases
* Environmental conditions: infectious diseases (eg, H. pylori, EBV(see section 2.6.5)), medical or surgical interventions (eg, gastric stumps)
(Long-standing non-self-limiting H. pylori gastritis (특히, atrophy가 있는) 가장 흔한 environmental preneoplastic condition)
<Abstract>
At the end of the last century, a far-sighted ’working party’ held in Sydney, Australia addressed the clinicopathological issues related to gastric inflammatory diseases. A few years later, an international conference held in Houston, Texas, USA critically updated the seminal Sydney classification. In line with these initiatives, Kyoto Global Consensus Report, flanked by the Maastricht-Florence conferences, added new clinical evidence to the gastritis clinicopathological puzzle. The most relevant topics related to the gastric inflammatory diseases have been addressed by the Real-world Gastritis Initiative (RE.GA.IN.), from disease definitions to the clinical diagnosis and prognosis. This paper reports the conclusions of the RE.GA.IN. consensus process, which culminated in Venice in November 2022 after more than 8months of intense global scientific deliberations. A forum of gastritis scholars from five continents participated in the multidisciplinary RE.GA.IN. consensus. After lively debates on the most controversial aspects of the gastritis spectrum, the RE.GA.IN. Faculty amalgamated complementary knowledge to distil patient-centred, evidence-based statements to assist health professionals in their real-world clinical practice. The sections of this report focus on: the epidemiology of gastritis; Helicobacter pylori as dominant aetiology of environmental gastritis and as the most important determinant of the gastric oncogenetic field; the evolving knowledge on gastric autoimmunity; the clinicopathological relevance of gastric microbiota; the new diagnostic horizons of endoscopy; and the clinical priority of histologically reporting gastritis in terms of staging. The ultimate goal of RE.GA.IN. was and remains the promotion of further improvement in the clinical management of patients with gastritis.