Gastritis

As always, today's post is available in podcast form on www.medonthego.podbean.com and feel free to check out our Facebook page www.facebook.com/drolimedonthego.

Today we discuss another common problem that many people have experienced at one time or another—gastritis! Let’s start with a review of stomach functions:

 Gastritis is defined histologically as inflammation of the stomach mucosa. There are many different causes of gastritis; sometimes one cause can result in different types of gastritis, and sometimes one person can many causes for gastritis.

Updated Sydney Classification of Gastritis (and etiology):

·      Acute gastritis

o   Hemorrhagic/erosive gastritis

§  Alcohol

§  Aspirin/NSAIDs

§  Shock/physiological stress (ICU patients)

o   Helicobacter gastritis

§  H. pylori

·      Chronic gastritis

o   Non-atrophic

§  H. pylori

o   Atrophic

§  H. pylori

§  Dietary

§  Autoimmunity

§  Environmental factors (multi-focal)

o   Chemical

§  NSAIDs

§  Bile

o   Radiation

§  Radiation injury

o   Lymphocytic

§  Celiac disease

§  Drugs

o   Eosinophilic

§  Food allergies

o   Non-infectious granulomatous

§  Crohn’s disease

§  Sarcoidosis

o   Other infectious gastritides

§  Bacteria

§  Viruses

§  Fungi

§  Parasite

§  Tuberculosis

§  Syphilis

In regards to clinical features, non-erosive gastritis is asymptomatic (except in certain causes such as Crohn’s disease) and does not cause pain—making it difficult to diagnose clinically or endoscopically. The diagnosis requires biopsy. Erosive gastritis can cause bleeding (usually without pain; pain only if progresses to ulcers, which is rare) and can be seen endoscopically.

Treatment is determined by etiology specific to the patient. Adjuvant non-pharmacological management includes avoidance of mucosal irritants such as alcohol, NSAIDs, and foods that trigger symptoms.

Case study:

A 76 year-old woman presents to the clinic with generalized weakness and dizziness, so severe that she has had difficulty walking by herself. She reported increasing fatigue and dizziness for the past one week. She denies any chest pain, shortness of breath, palpitations, diarrhea, or black stools.

She does not smoke or drink. She is not on any regular medications but takes some over-the-counter naproxen for joint pain occasionally.

On examination she has pale pink mucosa, orthostatic hypotension, mild epigastric tenderness.

Q: What tests would you order?

A: The following blood tests should be ordered:

·      Complete blood count to assess for anemia, as acute gastritis can cause gastrointestinal bleeding; elevated white cell count may indicate infectious cause

·      Liver and kidney function tests

·      Gallbladder and pancreatic function tests

·      H. pylori serology

Stool occult bloods should be ordered, as well as an endoscopy/colonoscopy to search for a cause of bleeding.

Her hemoglobin is 8 gm/dl and hematocrit 25%. Other routine admission labs are within normal limits. She tested positive for occult stool. Esophogastric endoscopy reveals erosive hemorrhagic gastritis, and a biopsy is performed.

Q: What are the differential diagnoses for this patient?

A: Also consider the following in the differential diagnosis of patients with suspected

•    Acute Complications of Sarcoidosis


•    B-Cell Lymphoma


•    Cholecystitis


•    Crohn’s Disease


•    Gallstones (Cholelithiasis)


•    Gastric Cancer


•    Peptic Ulcer Disease


•    Viral Gastroenteritis

•    Granulomatous gastropathy

Q: What factors may have led to this patient’s bleeding?

A: Although the patient may possibly have H. pylori and associated gastritis, the most common cause of hemorrhagic gastritis in the elderly is medication, especially aspirin and NSAIDs.

Q: Why did this patient not have pain?

A: Elderly patients with NSAID-associated gastric or duodenal damage are often asymptomatic until upper gastrointestinal bleeding or perforation occurs. Bleeding may be gradual, intermittent, and insidious, only showing up on chemical testing.

Q: How should the gastritis be managed?

A: Gastritis induced by NSAIDs without H. pylori infection should be treated with a proton-pump inhibitor or a histamine-2 blocker. NSAID use should be discontinued! If NSAIDs are absolutely necessary, short-acting agents such as ibuprofen, in the lowest possible dose, can be used.

Q: How should her joint pain be managed in the future?

A: Mild joint pain often responds to acetaminophen, and opioid/opioid-like analgesics can be helpful in patients who cannot tolerate NSAIDs. Topical agents such as capsaicin, transdermal lidocaine, and over-the-counter creams containing salicylates or cooling agents like menthol may be useful. Non-pharmacologic therapies such as weight reduction, walking aids, shoe insoles, braces, and prescribed exercises can reduce pain and improve function in some patients. Heat/cold, electrotherapeutics, ultrasound, and acupuncture may also be helpful.