Gastritis Flashcards
Define gastritis
Histological presence of gastric mucosal inflammation. The broader term gastropathy encompasses lesions characterised by minimal or no inflammation.
Epidemiology
- 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
Aetiology - acute non-erosive gastritis
- Helicobacter pylori infection
Aeitiology - Acute erosive gastritis
- 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)
Aetiology - Autoimmune-mediated atrophic gastritis
development of antibodies to the gastric
parietal cells
- thyroid disease
- idiopathic adrenocortical insufficiency
- vitiligo
- T1DM
- hypoparathyroidism
- North European or Scandinavian ancestry
Aetiology - Phlegmonous gastritis
- uncommon form of acute gastritis caused by Staphylococcus aureus , streptococci, Escherichia coli , Enterobacter , other gram-negative bacteria, and Clostridium welchii
Pathophysiology - H pylori
severe inflammatory response with gastric mucin degradation
and increased mucosal permeability, followed by gastric epithelial cytotoxicity
Pathophysiology - NSAIDs/alcohol
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
Pathophysiology - Autoimmune atrophic gastritis
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
Presentation of gastritis
- 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
Investigations
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
Considerations about PPIs and H. pylori testing
2 week ‘washout period’ required
Bismuth, and antibiotics can also affect it - 28 day washout period before test
What will the FBC show
autoimmune gastritis: variable; may show reduced haemoglobin and haematocrit and increased MCV (Low serum b12 = macrocytic anaemia)
Phlegmonous gastritis: leukocytosis with left shift
Which patients should be referred for 2WW endoscopy referral
with dysphagia or
aged 55 and over with weight loss and any of the following:
-upper abdominal pain
-reflux
-dyspepsia
Differentials for gastritis
- Peptic ulcer
- GORD
- If neg H pylori and endoscopy -> non-ulcer dyspepsia
- Gastric malignancy (lymphoma or carcinoma)
Management: H.pylori
- Triple therapy for 7 days BD
- PPI + amoxicillin + clarithromycin/metronidazole
- 2nd line: Quadruple therapy (previously treated with clarithromycin) - 7 days
- PPI + bismuth + metronidazole + tetracycline
Management: erosive gastritis
Discontinue NSAIDs + abstain from alcohol
If NSAIDs must be continued, co-prescribe a PPI
Management: autoimmune gastritis
Hydroxycobalamin 1mg IM three times a week for 2 weeks.
Management: bile reflux gastritis
- symptomatic therapy with rabeprazole +/- hydrotalcite or sucralfate
- surgical: Roux en Y
Management: phlegmonous gastritis
- ICU + fluid resus
- empiric broad-spectrum antibiotics
- Vasopressor (noradrenaline)
- ?Gastrectomy
Prevention: stress gastritis
- H₂ antagonists (famotidine or cimetidine) or a proton-pump inhibitor (PPI) (esomeprazole or pantoprazole)
- 2nd line: misoprostol or sucralfate
Risk factors: stress gastritis
- 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
Antibiotic management of phlegmonous gastritis
- Ampicillin + ciprofloxacin
- Piperacillin/tazobactam + clindamycin
Retesting
Carbon breath test
- patients requiring gastric acid suppression, histamine2-receptor antagonists should be used.
- AT LEAST 4 weeks after antibacterial treatment (2 of PPI)
Long-term complications
Gastric cancer (carcinoma, carcinoid, lymphoma) - low risk
Variable-term complication
Vit B12 deficiency (medium risk)
Peptic ulcer disease (medium risk)
Achlorhydria - decreased/absent production of HCl (atrophic gastritis) - high risk
