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Gastritis

BASICS

  • Inflammation of gastric mucosa
  • Acute: neutrophilic infiltration; Chronic: mononuclear infiltration (lymphocytes, macrophages)
  • Subtypes: erosive, reflux, hemorrhagic, infectious (H. pylori, CMV, EBV), atrophic (autoimmune), granulomatous (Crohn, sarcoidosis)
  • Common in elderly, rare in children (except H. pylori)

EPIDEMIOLOGY

  • Affects all adults; incidence increases with age
  • Equal sex distribution except autoimmune gastritis (female > male)
  • ~50% >60 years infected with H. pylori; higher in minorities, immigrants, low SES

ETIOLOGY AND PATHOPHYSIOLOGY

  • Noxious agents disrupt mucosal barrier → epithelial injury
  • Causes: H. pylori (most common), NSAIDs, alcohol, bile reflux, viral infections, stress
  • Autoimmune gastritis linked to pernicious anemia and gastric cancer risk
  • Genetic factors (TLR1) under investigation

RISK FACTORS

  • Age >60 years
  • NSAIDs, alcohol, tobacco
  • ICU patients with hypovolemia/hypoxia
  • Autoimmune diseases (thyroiditis, diabetes type 1, Addison's)
  • Family history of H. pylori or gastric cancer

GENERAL PREVENTION

  • Avoid mucosal irritants (NSAIDs, alcohol, tobacco)
  • ICU prophylaxis with H2 blockers, PPIs, prostaglandins, sucralfate
  • Test and treat H. pylori in long-term NSAID users or endemic populations

COMMONLY ASSOCIATED CONDITIONS

  • Peptic ulcer disease
  • Pernicious anemia
  • Portal hypertension gastropathy
  • MALT lymphoma

DIAGNOSIS

History

  • Burning epigastric pain, worse with eating
  • Nausea, vomiting, weight loss
  • Possible GI bleeding (melena, hematemesis)
  • Neurologic symptoms if B12 deficiency (atrophic gastritis)
  • Risk factor inquiry: NSAIDs, alcohol, autoimmune disorders

Physical Exam

  • Often normal; mild epigastric tenderness
  • Signs of anemia or chronic alcohol use

Differential Diagnosis

  • Dyspepsia (functional abdominal pain)
  • Peptic ulcer disease
  • Gastric cancer
  • Pancreatitis or biliary disease

DIAGNOSTIC TESTS & INTERPRETATION

  • Stool antigen and 13C-urea breath test for H. pylori (95% sensitivity/specificity)
  • Serum IgG for H. pylori (less useful post-treatment)
  • Endoscopy with biopsy for histology, rapid urease test, culture, PCR
  • Lab evaluation for anemia, B12 deficiency
  • Hold PPIs 2 weeks, H2 blockers 24 hours, antibiotics 4 weeks before testing

TREATMENT

General Measures

  • Eradicate H. pylori if present
  • Discontinue NSAIDs, alcohol, tobacco
  • Supportive care with fluids if needed

Medications

  • Antacids and H2 blockers for symptom relief
  • PPIs if refractory to H2 blockers
  • H. pylori treatment:
  • Clarithromycin triple therapy (amoxicillin/metronidazole + clarithromycin + PPI) 14 days
  • Bismuth quadruple therapy for resistant strains or penicillin allergy
  • Levofloxacin-based therapy for multiple failures
  • Probiotics may reduce symptoms but do not eradicate H. pylori

Pregnancy

  • Avoid certain antacids (sodium carbonate, magnesium trisilicate)
  • Defer H. pylori treatment if possible

SURGERY/OTHER PROCEDURES

  • Rarely required except for phlegmonous gastritis or high-grade dysplasia

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Cranberry, garlic, curcumin, ginger, Pistacia gum may have anti-inflammatory effects

ONGOING CARE

  • Confirm eradication >4 weeks post-therapy
  • Repeat endoscopy if severe disease or poor response
  • Surveillance for atrophic gastritis and dysplasia as indicated

DIET

  • Bland diet during symptoms
  • Avoid caffeine, spicy foods, alcohol, peppermint, carbonated drinks, high fat

PATIENT EDUCATION

  • Smoking cessation and alcohol limitation
  • Avoid NSAIDs
  • Relaxation techniques

PROGNOSIS

  • Generally good with treatment
  • Phlegmonous gastritis carries 40-50% mortality

COMPLICATIONS

  • Mucosal bleeding, ulceration
  • Gastric outlet obstruction
  • Gastric intestinal metaplasia and cancer risk
  • Atrophic gastritis associated with neuroendocrine tumors and adenocarcinoma

REFERENCES

  1. Yang H, Guan L, Hu B. Detection and treatment of Helicobacter pylori: problems and advances. Gastroenterol Res Pract. 2022;2022:4710964.
  2. Malfertheiner P, Megraud F, O'Morain CA, et al; European Helicobacter and Microbiota Study Group. Management of Helicobacter pylori infection—the Maastricht V/Florence consensus report. Gut. 2017;66(1):6-30.
  3. Chey WD, Leontiadis GI, Howden CW, et al. ACG clinical guideline: treatment of Helicobacter pylori infection. Am J Gastroenterol. 2017;112(2):212-239.
  4. Buzás GM, Birinyi P. Newer, older, and alternative agents for the eradication of Helicobacter pylori infection: a narrative review. Antibiotics (Basel). 2023;12(6):946.

CODES

  • ICD10: K29.5 Unspecified chronic gastritis
  • ICD10: K29.40 Chronic atrophic gastritis without bleeding
  • ICD10: K29.50 Unspecified chronic gastritis without bleeding

CLINICAL PEARLS

  • H. pylori is the leading cause of gastritis; >50% adults colonized by age 60.
  • Antibody tests for H. pylori should not be used to assess eradication.
  • Stool antigen and urea breath tests are reliable for diagnosis and post-treatment follow-up.
  • Discontinue PPIs 2 weeks prior to endoscopy to improve diagnostic accuracy.
  • Multiple treatment regimens may be needed for eradication due to resistance.