Hierarchical diagnostic and therapeutic approach for chronic atrophic gastritis based on the perspective of multiple attribution

Chronic atrophic gastritis (CAG) is a common gastric pre-cancerous disease, which is in the initial stage of the gastritis-cancer transformation process. Its etiology and pathogenesis are complicated, and a single etiology cannot explain the combination of deficiency, excess, cold, and heat. In this study, the complex pathogenesis and overall syndrome differentiation and treatment strategy of CAG are systematically analyzed in the framework of multiple attribution perspective. Based on the traditional Chinese medicine theory of "the unity of heaven, earth, and human," it constructs a three-level progressive attribution system of "spleen-stomach, brain-gut, environment," where the three layers of attribution are interlocking and mutually causal. The primary attribution refers to the core view of spleen and stomach, emphasizing that "malnutrition of gastric collaterals" is the key pathogenesis of this disease. Deficiency leads to insufficient qi and blood, whereas excess results in the intermingling of phlegm, blood stasis, and toxins, which serve as the basis for disease onset and leads to the development of pathogenesis. The therapeutic principle should be "tonifying the spleen and eliminating masses." For deficiency patterns, tonify the spleen; for excess patterns, resolve masses. By focusing on the root of the spleen and stomach, regulate the body form to consolidate the middle energizer. The secondary attribution pertains to the interaction view of brain-gut, proposing that "brain-gut disharmony" is a key factor in disease occurrence. It can damage the spleen and stomach and aggravate the microscopic malnutrition of gastric collaterals. Conversely, impaired spleen-stomach function can also lead to insufficient qi and blood production, making it difficult to nourish the brain and spirit, thereby forming a vicious circle of "brain-gut comorbidity." Therefore, harmonizing the relationship between the brain and gut and regulating qi to calm the spirit and soul is essential. The tertiary attribution relates to the holistic view of the correspondence between nature and humans, emphasizing that external factors such as regional climate and social pressure interact with constitutional endowment to cause disease—that is, the natural and social environments exert pathogenic effects by influencing the first two attributions. Clinically, prescriptions should be formulated according to the differences in regional cold-heat characteristics and qi transformation of the four seasons, and combined with exercise guidance and psychological counseling to regulate both the body form and spirit simultaneously, i.e., conform to the way of heaven and earth and regulate the spirit to harmonize between nature and human. The three attributions are constructed progressively, layer by layer, to jointly form a three-level syndrome differentiation system and a hierarchical treatment strategy for CAG.