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Gastritis

Gastritis, an inflammation of the gastric mucosa, is frequently triggered by H. pylori infection or NSAID use. Presenting with dyspepsia, it’s often managed via a test-and-treat approach for H. pylori unless upper endoscopy is indicated. Endoscopy, necessary for a definitive diagnosis, is recommended for patients over 60 or those with dyspepsia red flags. It can reveal histopathological signs of inflammation and sometimes uncovers gastritis incidentally. While the cause may be apparent, such as medication-induced injury, additional tests might be needed to ascertain the etiology and tailor the treatment. Treatment options include H. pylori eradication therapy or acid suppression pharmacotherapy, depending on test results.

Last updated: February 20, 2024 130 views

  • Gastritis:
    • Defined as inflammation of the gastric mucosa.
    • Commonly a response to:
      • Helicobacter pylori infection (H. pylori gastritis).
      • Direct injury (e.g., substance-induced gastritis).
      • Systemic inflammatory diseases.
  • Gastropathy:
    • Refers to injury to the gastric mucosa.
    • Typically involves disruption of the protective mucous barrier.
    • Distinguished by minimal or no inflammation, unlike gastritis.

  • External Causes:
    • Infectious:
      • Bacterial (e.g., H. pylori, Mycobacterium tuberculosis, Treponema pallidum).
      • Viral (e.g., CMV, EBV).
      • Fungal (e.g., Candida spp.).
      • Parasitic (e.g., Anisakis spp.).
    • Noninfectious:
      • Alcohol.
      • Medications (e.g., NSAIDs, aspirin).
      • Chemotherapy.
      • Radiation.
  • Patient-Related Causes:
    • Systemic Diseases:
      • Crohn's disease.
      • Vasculitis (e.g., IgA vasculitis, ANCA-associated vasculitis).
      • Mesenteric ischemia.
    • Immune-Mediated:
      • Autoimmune metaplastic atrophic gastritis (AMAG).
      • Lymphocytic gastritis, eosinophilic gastritis.
      • Non-IgE mediated food allergies.
    • Other:
      • Ménétrier disease.
      • Physiological stress (e.g., trauma, burns, critical illness).
      • Idiopathic.

 

Note  
Helicobacter pylori infection is the most common cause of gastritis. ملاحظة

  • Acute Gastritis:
    • Inflammation with predominantly neutrophilic infiltrate.
    • Often denotes self-limiting symptoms.
  • Chronic Gastritis:
    • Inflammation with predominantly mononuclear infiltrate; loss of normal tissue architecture.
    • Associated with long-term or recurring symptoms.
  • Atrophic Gastritis:
    • Chronic inflammation leading to loss of native glands.
    • Inflammation replaced by fibrosis or metaplastic changes (intestinal metaplasia or pseudopyloric gland metaplasia).
  • Nonatrophic Gastritis:
    • Chronic inflammation without atrophic changes.
    • Potential for mucosal recovery or progression to atrophy.
  • Erosive Gastritis:
    • Superficial erosions not extending beyond muscularis mucosae, may cause bleeding.
    • Subtypes:
      • Stress-Induced Gastritis: Acute erosions/hemorrhages due to critical conditions (e.g., sepsis, shock).
      • Reactive Gastropathy: Mucosal injury from chronic exposure to irritants (e.g., bile reflux, alcohol, NSAIDs, aspirin).
      • May progress to an ulcer.

  • Typical Symptoms:
    • Dyspepsia: Discomfort or pain in the upper abdomen.
    • Postprandial Fullness: Feeling excessively full after meals.
    • Early Satiety: Feeling full after eating small amounts of food.
    • Bloating: Abdominal swelling or feeling of fullness.
  • Typical Signs:
    • Epigastric Tenderness: Localized pain in the upper central region of the abdomen, without signs of peritoneal irritation.
  • Atypical Symptoms (Concerning for GI Malignancy):
    • Unintentional Weight Loss: Losing weight without trying, which can be a warning sign of a serious condition.
    • Progressive Dysphagia: Increasing difficulty in swallowing, which can indicate a more serious underlying issue.

  • Acute Hemorrhagic Erosive Gastropathy:
    • Definition: Gastric mucosa injury due to acute exposure to harmful substances.
    • Etiology: NSAIDs, aspirin, alcohol, caffeine, corrosive substances, certain supplements, ischemic injury.
    • Pathophysiology: Direct mucosal injury leading to edema, hyperemia, erosion, ulceration.
    • Clinical Features: Symptoms of gastritis, nausea/vomiting, occult/massive bleeding.
    • Treatment: Discontinue causative drugs, abstain from tobacco/alcohol, avoid exacerbating substances, PPI therapy.
  • Reactive Gastropathy:
    • Definition: Chronic exposure to irritants causing gastric mucosa injury.
    • Etiology: Chronic NSAID or alcohol use, bile reflux.
    • Clinical Features: May be asymptomatic or present with abdominal pain, nausea/vomiting, weight loss.
    • Treatment: Discontinue causative agents, surgery for bile acid reflux gastropathy.
    • Complications: Obstruction, bleeding, perforation.
  • Ménétrier Disease:
    • Definition: Characterized by massive enlargement of mucosal folds.
    • Pathophysiology: Foveolar hyperplasia, increased mucus, atrophy of parietal cells, hyperplasia of gastric rugae.
    • Clinical Features: Dyspeptic symptoms, protein-loss gastropathy, hypoalbuminemia, peripheral edema.
    • Diagnostics: Endoscopic and histopathological findings, CT scan.
    • Management: Supportive care, test-and-treat for H. pylori, cetuximab or total gastrectomy in severe cases.
    • Complications: Peripheral edema, malignant degeneration.
  • Specific Infiltrates:
    • Granulomatous Gastritis: Granulomas in gastric mucosa due to infectious (e.g., tuberculosis) or noninfectious causes (e.g., Crohn's disease).
    • Eosinophilic Gastritis: Eosinophilic infiltration, often linked with allergic diseases. Managed with antacids, acid suppression, swallowed aerosolized steroids, elimination diet.
    • Lymphocytic Gastritis: Lymphocytic infiltration, possibly autoimmune or allergic in origin.

  • Overall Diagnostic Approach:
    • Gastritis is typically diagnosed via gastric mucosal biopsy.
    • Not all patients with upper GI symptoms require invasive testing.
    • Initial step for most: Test-and-treat strategy for H. pylori.
  • Upper Endoscopy and Biopsies:
    • Indications:
      • Recommended for patients > 60 years old.
      • Consider for patients with red flags of dyspepsia (e.g., signs of malignancy, bleeding, systemic disease).
      • For those with insufficient response to initial medical management.
    • Additional Studies:
      • Based on individual evaluation and clinical suspicion.
      • Detect complications (e.g., decreased hemoglobin, increased BUN/Cr ratio for GI bleeding).
      • Evaluate differential diagnoses (e.g., liver chemistries, lipase, amylase for hepatic/pancreatic disease).
      • Identify underlying etiology (e.g., inflammatory markers, antibody testing for systemic inflammatory or autoimmune diseases).
  • Esophagogastroduodenoscopy (EGD) with Biopsies:
    • Endoscopic Findings:
      • May appear macroscopically normal.
      • Possible mucosal hyperemia and edema, erosion with/without bleeding.
      • Atrophy or metaplasia, indicating atrophic gastritis.
      • Other findings in specific gastritis types (e.g., enlarged mucosal folds in hypertrophic gastritis).
    • Histopathologic Findings:
      • Vary based on etiology (e.g., atrophy and gland loss in atrophic gastritis, eosinophilic infiltrate in eosinophilic gastritis).

  • General Treatment Approach:
    • Upper GI symptoms often initially treated empirically (refer to “Approach to dyspepsia”).
    • If gastritis is confirmed via upper endoscopy, treatment should be specific to the identified etiology.
  • Pharmacological Therapy:
    • H. pylori Eradication Therapy: For cases where H. pylori is the underlying cause.
    • Antacids and Acid Suppression Medications: To manage symptoms and promote mucosal healing.
  • Nonpharmacological Therapy:
    • Dietary and Lifestyle Modification: Implement changes to reduce symptoms.
    • Trigger Avoidance: Avoid known irritants like NSAIDs, tobacco, caffeine, alcohol.
  • Specific Treatments Based on Etiology: Refer to “Subtypes and variants” for targeted treatments depending on the subtype of gastritis diagnosed.
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