| Objective:the first part of this study aims to explore the quantitative evaluation methods of Traditional Chinese Medicine discrimination(symptoms,tongue,and pulse diagnosis)combined with endoscopic micro-differentiation of discrimination,to establish the identification method for high-risk patients with chronic atrophic gastritis(CAG)with spleen deficiency and blood stasis.The study also investigates the correlation between spleen deficiency and blood stasis syndrome in patients with CAG and the risk of gastric cancer,providing a basis for the establishment of a combination of disease and syndrome identification method for high-risk patients with CAG in both Chinese and Western medicine.The second part of the study uses the OLGIM(Operative Link on Gastric Intestinal Metaplasia Assessment)risk assessment results as a reference to examine the performance of the KimuraTakemoto Classification(K-T classification)tool for identifying high-risk patients with CAG under endoscopy.The study also explores the endoscopic factors that cause differences between the results of the two methods.The study attempts to establish a combination of K-T classification and pathological diagnosis for identifying high-risk patients and tests its efficiency.Methods:This study selected patients with CAG who visited the Department of Spleen and Stomach Diseases,inpatient ward,and Digestive Endoscopy Center of Xiyuan Hospital,China Academy of Chinese Medical Sciences from January 2022 to February 2023 as the research subjects.The study was divided into two parts.The first part used a cross-sectional study to collect patients’ general information,risk factors,endoscopic and pathological data,and to collect patients’ symptoms,tongue,and pulse diagnosis for quantized integration of spleen deficiency and blood stasis syndrome.A database was established,and SPSS 26.0 statistical software was used to analyze the association between spleen deficiency,blood stasis syndrome,and CAG risk factors in patients,the consistency of traditional Chinese medicine syndrome differentiation and endoscopic micro-differentiation of discrimination in spleen deficiency and blood stasis syndrome,and the correlation between spleen deficiency,blood stasis syndrome scores,and CAG progression risk.The second part was a retrospective cross-sectional study,in which patients’ endoscopic and pathological data were collected,and a database was established.SPSS 26.0 statistical software was used to analyze the consistency between endoscopic diagnosis and histopathological diagnosis of CAG in patients,the factors influencing the difference in identifying high-risk patients between K-T classification and OLGIM staging,the endoscopic factors that may affect OLGIM staging risk,and the consistency of the results of K-T classification combined with pathological biopsy and OLGIM staging in identifying high-risk patients with CAG.Result:Topic 1:A total of 62 patients with CAG were included,including 37 low-risk patients and 25 high-risk patients.A total of 58 patients(93.5%)were diagnosed with spleen deficiency syndrome,and 48 patients(77.4%)were diagnosed with blood stasis syndrome.Statistical analysis revealed that:(1)The three most common typical symptoms of spleen deficiency syndrome in the enrolled patients were:sallow complexion(49 cases,79.0%),fatigue(38 cases,61.3%),and abdominal distension(36 cases,58.1%);the degree of symptoms was mostly mild to moderate.Mixed red and white shades of mucosa and mucosal granules or nodules were seen in all patients included in this study by gastroscopy.Common mucosal changes included edema(56 cases,90.3%),thinning of the mucosa with a pale or gray-white color(42 cases,67.7%),and bleeding mucosal spots or plaques(40 cases,64.5%).(2)Among the 13 dietary habits,including frequently eating takeout food,irregular meals,skipping breakfast/lunch/dinner,eating before sleep,irregular hunger/satiety,consuming leftover food,greasy food,high-temperature processed food,sweets,spicy food,raw/cold food,high-salt pickled food,and drinking coffee/strong tea,patients who had these habits had higher scores for spleen deficiency syndrome symptoms,but the differences were not statistically significant(P>0.05).(3)In the micro-differentiation of spleen deficiency syndrome,the following seven manifestations had higher mean scores in those who exhibited them,but the differences were not statistically significant(P>0.05):mucosal edema,flat or even absent folding of the mucosa,thin and clear mucus,weakened gastric peristalsis,reduced mucosal elasticity,mucosal thinning,pallor or grayish-white color,and clear submucosal vessels.In the microdifferentiation of blood stasis syndrome,one manifestation,namely,dark red mucosa,showed a significant difference in symptom scores between those with and without symptoms(P=0.007<0.01).The mean scores for blood stasis syndrome symptoms were higher in patients with limited mucosal swelling,bleeding spots or patches,dark red mucosa,and clear purple or dark vascular network,but the differences were not statistically significant(P=0.364,0.138,0.124,all>0.05).(4)The mean scores of spleen deficiency and blood stasis syndromes increased with the degree of EGA/IM,and the scores for the open-type group were higher than those for the closed-type group in the K-T classification.The mean scores of spleen deficiency and blood stasis syndromes were higher in the OLGA/OLGIM high-risk group than in the low-risk group.The differences in micro-differentiation scores for spleen deficiency and blood stasis were statistically significant(P<0.001)among patients with different degrees of EGA/IM.Three items,namely,blood stasis syndrome symptom score(P=0.029<0.05),and micro-differentiation scores for spleen deficiency(P<0.001)and blood stasis syndrome(P=0.006<0.01),showed statistically significant differences among different K-T classifications.The mean scores of micro-differentiation for spleen deficiency and blood stasis syndrome were statistically significant(P=0.003<0.01,P<0.001)among different risk groups.The total scores for blood stasis syndrome and spleen deficiency and blood stasis syndrome in the high-risk group were higher than those in the low-risk group,and the differences were statistically significant(P<0.001,P=0.012<0.05).The mean total score for spleen deficiency syndrome in the high-risk group was higher than that in the low-risk group,but the difference was not statistically significant(P=0.278>0.05).Topic 2:A total of 188 patients with chronic atrophic gastritis(CAG)who underwent gastroscopy or pathological diagnosis were included,including 112 lowrisk patients and 76 high-risk patients.Statistical analysis showed that:(1)In this study,the results of the Kappa consistency test analysis showed that the consistency between the K-T classification evaluation of atrophy degree and the pathological biopsy results was moderate(Kappa:0.214,P<0.01,95%CI:0.115-0.312).The consistency between the K-T classification degree(none/mild,moderate/severe)risk judgment and OLGIM staging risk result was moderate(Kappa:0.447,P<0.001,95%CI:0.312-0.582);the consistency between the K-T classification range(open type,close type)risk judgment and OLGA staging risk was moderate(Kappa:0.353,P<0.001,95%CI:0.209-0.496).(2)The inconsistency between K-T classification and pathological risk assessment was mainly concentrated in types C-2,C-3 and O-1,among which the proportion of C-3 inconsistency was 48.39%(15 cases)and O-1 inconsistency was 48.00%(12 cases).The K-T risk evaluation was higher in 27 cases and lower in 19 cases.In the two groups of K-T risk evaluation higher and consistent,the distribution of one item of vascular exposure was statistically significant(P=0.038<0.05);the mean difference of IM nodules and mucosal patches was statistically significant(P=0.022,0.003,both<0.05).In the two groups of K-T risk evaluation lower and consistent,the mean difference of mucosal edema score,Hp infection score and gastric antrum EGA/IM degree distribution were statistically significant(P both<0.001).Moderate/severe IM in the gastric antrum was an independent factor contributing to the difference in risk assessment between the two.(3)The proportion of patients with map-like redness in the high-risk group(50%)was significantly higher than that in the low-risk group(18.5%),and the difference was statistically significant(P<0.001);In this study,the degree of IM in the gastric angle biopsy was the highest among all biopsies,with 18 cases(9.89%);After excluding the biopsy results of the gastric angle,32 patients(17.59%)had a decrease in OLGIM staging results,including 16 patients(8.79%)whose risk level decreased from highrisk to low-risk.(4)The mean values of the K-T+IM/EGA scores in the high-risk group proposed in this study were significantly higher than those in the low-risk group,and the difference was statistically significant(P<0.001).The diagnosis of low/high-risk based on the Mukaida+IM score in 182 patients showed a strong consistency with the low/high-risk diagnosis based on OLGIM staging results(Kappa:0.735,P<0.001,95%CI:0.633～0.838).Conclusion:(1)Dark red mucosa is a microscopic manifestation of blood stasis syndrome.The microscopic differentiation of spleen deficiency and blood stasis syndrome is consistent with traditional differentiation,which can reflect the differences in different stages of disease progression to some extent and meet the needs of "treating the syndrome with differentiation".(2)There is a correlation between the degree of spleen deficiency and blood stasis in patients with chronic atrophic gastritis(CAG)and the extent of atrophy evaluated by the Kimura-Takemoto(K-T)classification,as well as the severity of histopathological features such as the extent of gastric glandular atrophy(EGA)and intestinal metaplasia(IM).Compared with the quantified scoring of spleen deficiency,quantified scoring of blood stasis is more helpful in screening high-risk CAG patients.A quantitative scoring system that combines macroscopic symptoms of spleen deficiency and blood stasis with microscopic differentiation is more sensitive in reflecting the differences between different risk groups than a purely traditional symptomatic quantitative scoring system.(3)The K-T classification evaluates the extent of atrophy to assess the progression of chronic atrophic gastritis(CAG),but it is not consistent with the actual pathological degree of atrophy.The agreement between K-T classification and OLGIM staging in identifying high-risk CAG patients is moderate,with C-3 type being a better threshold to identify high-risk patients.Visible blood vessels,IM nodules,and severe mucosal patchy redness observed during gastroscopy are factors that contribute to a higher risk evaluation with K-T classification.Severe mucosal edema,Hp infection or eradication,and extensive atrophy/IM in the gastric antrum are factors that contribute to a lower risk evaluation with K-T classification.Biopsy results from the angularis and map-like reddish areas of the stomach may affect the patient’s risk assessment level.(4)Moderate/severe IM in the gastric antrum was an independent factor contributing to the difference in risk assessment between the two.The K-T classification combined with pathological biopsy results can be used to assist in identifying high-risk patients. |
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