Gastritis

Question 1

Define gastritis

Answer 1

Histological presence of gastric mucosal inflammation. The broader term gastropathy encompasses lesions characterised by minimal or no inflammation.

Question 2

Epidemiology

Answer 2

• Dyspeptic symptoms are reported in 10% to 20% of patients taking non-steroidal anti-inflammatory drugs (NSAIDs)
• The prevalence of Helicobacter pylori infection is higher in developing countries

Question 3

Aetiology - acute non-erosive gastritis

Answer 3

• Helicobacter pylori infection

Question 4

Aeitiology - Acute erosive gastritis

Answer 4

• chronic non-steroidal anti-inflammatory drug (NSAID) or alcohol use/misuse (at higher risk if previous GI ulcer, >60yo, concurrent use of anticoagulants/corticosteroids)
• reflux of bile salts into the stomach as a result of compromised pyloric function (e.g., following gastric surgery)

Question 5

Aetiology - Autoimmune-mediated atrophic gastritis

Answer 5

development of antibodies to the gastric
parietal cells

• thyroid disease
• idiopathic adrenocortical insufficiency
• vitiligo
• T1DM
• hypoparathyroidism
• North European or Scandinavian ancestry

Question 6

Aetiology - Phlegmonous gastritis

Answer 6

• uncommon form of acute gastritis caused by Staphylococcus aureus , streptococci, Escherichia coli , Enterobacter , other gram-negative bacteria, and Clostridium welchii

Question 7

Pathophysiology - H pylori

Answer 7

severe inflammatory response with gastric mucin degradation
and increased mucosal permeability, followed by gastric epithelial cytotoxicity

Question 8

Pathophysiology - NSAIDs/alcohol

Answer 8

Both decrease gastric mucosal blood flow with loss of the mucosal protective barrier
- NSAIDs inhibit prostaglandin production, whereas alcohol
promotes depletion of sulfhydryl compounds in gastric mucosa

Question 9

Pathophysiology - Autoimmune atrophic gastritis

Answer 9

Antiparietal cell antibodies stimulate a chronic inflammatory, mononuclear, and lymphocytic infiltrate involving the oxyntic mucosa, leading to the loss of parietal and chief cells in the gastric corpus

Question 10

Presentation of gastritis

Answer 10

• presence of risk factors
• dyspepsia/epigastric discomfort
• nausea, vomiting, and loss of appetite

(uncommon) Symptoms of phlegmonous gastritis - severe emesis, fever, acute abdominal pain

(uncommon) Symptoms of clinical B12 deficiency - altered reflexes or sensory deficits, glossitis, cognitive impairment

Question 11

Investigations

Answer 11

H pylori - carbon-13 breath test or faecal antigen test
Bloods - FBC, serum B12, IF and GPC antibodies
Imaging - endoscopy (e.g. if treatment failed)
- H pylori rapid urease test
- gastric mucosal histology
- Upper GI contrast series CT

Question 12

Considerations about PPIs and H. pylori testing

Answer 12

2 week ‘washout period’ required
Bismuth, and antibiotics can also affect it - 28 day washout period before test

Question 13

What will the FBC show

Answer 13

autoimmune gastritis: variable; may show reduced haemoglobin and haematocrit and increased MCV (Low serum b12 = macrocytic anaemia)
Phlegmonous gastritis: leukocytosis with left shift

Question 14

Which patients should be referred for 2WW endoscopy referral

Answer 14

with dysphagia or

aged 55 and over with weight loss and any of the following:
-upper abdominal pain
-reflux
-dyspepsia

Question 15

Differentials for gastritis

Answer 15

• Peptic ulcer
• GORD
• If neg H pylori and endoscopy -> non-ulcer dyspepsia
• Gastric malignancy (lymphoma or carcinoma)

Question 16

Management: H.pylori

Answer 16

• Triple therapy for 7 days BD
• PPI + amoxicillin + clarithromycin/metronidazole
• 2nd line: Quadruple therapy (previously treated with clarithromycin) - 7 days
• PPI + bismuth + metronidazole + tetracycline

Question 17

Management: erosive gastritis

Answer 17

Discontinue NSAIDs + abstain from alcohol
If NSAIDs must be continued, co-prescribe a PPI

Question 18

Management: autoimmune gastritis

Answer 18

Hydroxycobalamin 1mg IM three times a week for 2 weeks.

Question 19

Management: bile reflux gastritis

Answer 19

• symptomatic therapy with rabeprazole +/- hydrotalcite or sucralfate
• surgical: Roux en Y

Question 20

Management: phlegmonous gastritis

Answer 20

• ICU + fluid resus
• empiric broad-spectrum antibiotics
• Vasopressor (noradrenaline)
• ?Gastrectomy

Question 21

Prevention: stress gastritis

Answer 21

• H₂ antagonists (famotidine or cimetidine) or a proton-pump inhibitor (PPI) (esomeprazole or pantoprazole)
• 2nd line: misoprostol or sucralfate

Question 22

Risk factors: stress gastritis

Answer 22

• Critically ill patients
• Mechanical ventilation for >48 hours and coagulopathy (platelet count <50)
• partial thromboplastin time >2 times the upper limit of the normal range
• INR >1.5

Question 23

Antibiotic management of phlegmonous gastritis

Answer 23

1. Ampicillin + ciprofloxacin
2. Piperacillin/tazobactam + clindamycin

Question 24

Retesting

Answer 24

Carbon breath test
- patients requiring gastric acid suppression, histamine2-receptor antagonists should be used.
- AT LEAST 4 weeks after antibacterial treatment (2 of PPI)

Question 25

Long-term complications

Answer 25

Gastric cancer (carcinoma, carcinoid, lymphoma) - low risk

Question 26

Variable-term complication

Answer 26

Vit B12 deficiency (medium risk)
Peptic ulcer disease (medium risk)
Achlorhydria - decreased/absent production of HCl (atrophic gastritis) - high risk