Gastritis

Background

Stomach anatomy

Stomach wall anatomy

• Inflammation of the stomach lining
• May occur acutely or chronically
• May lead to peptic ulcer disease
• Causes
  • H. pylori
  • NSAIDs
  • ETOH
  • Critical Illness (Cushing ulcer)
    • Increased ICP, stimulation of vagal nuclei, increased secretion of gastric acid

Clinical Features

• Gnawing or burning epigastric pain
• Nausea/vomiting
• Early satiety, bloating
• Heartburn

Differential Diagnosis

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

Evaluation

Conventional white-light endoscopic findings for the gastric body. (a) Normal (b) Gastric mucosa with chronic atrophic gastritis associated with HP infection. Visible vessels and an absence of folds in the gastric body mucosa are characteristic of chronic atrophic gastritis.

• CBC (to rule out anemia)
• BMP, LFTs
• Lipase
• Consider:
  • Acute abdominal series
  • ?Barium swallow (upper GI series)
  • Endoscopy (most will be done as outpatient)
  • RUQ US
  • ECG/troponin

Management

• Cessation of NSAIDs and ETOH
• Eradicate H. pylori if identified in symptomatic patient
  • Triple Therapy: PPI + clarithromycin 500mg BID + amoxicillin1g BID x 10-14d
    • Metronidazole 500mg BID can be substituted for amoxicillin in penicillin-allergic individuals
  • Quadruple Therapy: PPI + bismuth subsalicylate 524mg QID + metronidazole 250mg QID and tetracycline 500mg QID x 10-14d.
    • Can be used in areas of high resistance to clarithromycin or metronidazole

• PPI
  • Generally heal ulcers faster than H2 blockers
  • Omeprazole 20-40mg QD
• H2 blockers
  • Famotidine 20-40mg QD
  • Ranitidine 75-150mg BID

Disposition

• Normally outpatient management, unless complication (see below)

Red Flags

Any of the following suggest need for endoscopy referral:

• Age >55yr
• Unexplained weight loss
• Early satiety
• Persistent vomiting
• Dysphagia
• Anemia or GI bleeding
• Abdominal mass
• Persistent anorexia
• Jaundice

See Also

PUD