Gastritis

Introduction

Gastritis is a condition where the lining of the stomach is inflamed. It occurs typically from the late teens to old age. Children rarely develop it. Medically the lining of the stomach is called "mucosa". In the introduction of the next chapter on ulcers I am explaining that there is a fine balance of several factors regarding the integrity of the mucosa.

Gastritis

Introduction

Acute gastritis

Chronic gastritis

H.pylori

Symptoms

Diagnosis

Treatment

For instance, when a person is extremely stressed (severe burns, head trauma, kidney or liver failure, shock etc.), the extra amount of acid production from the stimulation of ACTH production (stress hormone) coupled with a weakening effect of cortisol from the adrenal glands on the repair mechanisms of the mucosa will tip the balance.

Acute gastritis

Within only two to five days of such a major crisis as listed above acute stress gastritis will occur in a significant percentage. With the use of non-steroidal anti inflammatory drugs (NSAIDs) for arthritis or sports injuries the rate of acute erosive gastritis has increased. Alcohol abuse can cause the same thing. On endoscopy this condition can be diagnosed by the presence of spots of erosive changes throughout the stomach, but confined to the superficial layers. There is submucosal (petechial) bleeding associated with it.

H.Pylori

Another form of gastritis is the nonerosive gastritis. This type of gastritis is associated with the bacterium H. pylori. If this is not treated, as we learn in the next chapter, it can go on to chronic ulcers of the stomach and duodenum.

After decades of infection it can even lead to stomach cancer (adenocarcinoma of the stomach). In development countries H.pylori is very common and is usually acquired in childhood. In the U.S.A. it is rare in children and is more common in blacks and Hispanics than whites. It increases in frequency with age. It can be cultured from dental plaque and dental cavities, saliva and stool. Further comments about tests can be found under "diagnosis" of the chapter on "gastrointestinal diseases/ulcers" below. Non erosive gastritis is a superficial inflammatory change of the mucosa, which shows characteristic inflammatory cell infiltration on biopsy specimens taken by endoscopy. These more chronic forms of gastritis need the skills of an experienced gastroenterologist. The specialist may over the years have to do several gastroscopies with various attempts to culture bacteria and to take brushing samples for histological analysis to rule out malignancies. It may take several months of such testing before the specialist can give you a clear picture of what is going on inside.

Chronic gastritis can lead to three histological conditions: deep gastritis, gastric atrophy or metaplasia. Each of them have characteristic pathological appearances under the microscope and they have certain clinical significance as I will briefly mention. Deep gastritis is often associated with H.pylori infection and should be treated, as untreated it likes to progress to chronic ulcers(next chapter).

Gastric atrophy is often found in older patients and is associated with autoantibodies against the acid producing cells of the gastric mucosa. This in turn leads to vitamin B12 malabsorption, a condition known as pernicious anemia. Metaplasia is found in some cases of severe atrophy and patches of gastric mucosa have been replaced with mucosa, which looks more like intestinal mucosa ("metaplasia"). This condition is important to watch as it can degenerate into stomach cancer.

Symptoms of gastritis

With acute stress gastritis the patient is too ill to communicate any symptoms. The physician in the ICU setting might therefore do an endoscopy to see whether or not stress ulcers are present.

If acute stress gastritis is not treated promptly, there is a high mortality rate from acute gastric or duodenal ulcerations, which can fairly quickly develop and from which profuse bleeding can occur. About 2% of ICU patients will develop profuse bleeding from stress ulcers. The mortality rate in these cases is in the order of 60 to 70% depending on the underlying disease.

Generally speaking, most gastritis cases are mild and of a more chronic nature.

Depending on how the pathology is, the severity of symptoms will vary. Some patients with nonerosive gastritis may hardly feel any symptoms at all, maybe some nausea or discomfort in the mid upper abdomen. If the pathology involves deeper aspects of the mucosa of the stomach, vomiting and more severe abdominal cramps, some burning and a "hunger feeling" are also not unusual. Sometimes there might be pain irradiating into the mid chest area and be confused with a heart attack. Particularly with biliary gastritis, where bile acids are flowing back into the stomach the symptoms can be fairly acute and vomiting occurs more frequently.

Diagnosis

Mild cases are made on clinical grounds and treated according to the principles of the acid reflux chapter above. If H2-blockers do not give relief, there should be a high suspicion that perhaps H.pylori could be the reason for the gastritis.

The urea breath test (see next chapter)should be done to test that possibility. If it is positive, then a triple therapy program for one week would be successful in over 90% of the cases (see Ref. 1). This is a combination of amoxicillin and clarithromycin with a proton inhibitor or else a combination of clarithromycin and metronidazole with a proton pump inhibitor. If this fails, or if the symptoms are worse, endoscopy (also called "gastroduodenoscopy"or "panendoscopy") is suggested, which is usually done by a gastroenterologist, but in smaller towns may still be done by a surgeon or internist. This allows the specialist to visually diagnose the condition and do biopsies to establish the severity of the gastritis to rule out a malignancy, if there are suspicious areas. A sample of secretions can also be tested directly with the rapid urease test for H.pylori.

Treatment

With positive test results triple therapy as mentioned above is ordered. With atrophic gastritis B12 injections have to be given regularly every months and the patient can learn how to do this him/herself. This will prevent the development of pernicious anemia. Gastric mucosa normally secretes a protein called intrinsic factor, which binds to the vitamin B12 of the food and gets absorbed in the small bowel. Patients with atrophic gastritis lack the intrinsic factor and that's why this inexpensive vitamin needs to be given by injection. For the ordinary gastritis the antacid medications cimetidine, ranitidine or the stronger antacid medicines (proton pump inhibitors) are used for a few weeks.

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Disclaimer:

This outline is only a teaching aid to patients and should stimulate you to ask the right questions when seeing your doctor. However, the responsibility of treatment stays in the hands of your doctor and you.

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Last Modified: Nov. 27, 2007