Author:
Yanina A.Purim-Shem-Tov
Description
- Inflammatory response of gastric mucosa to injury - “gastritis”
- 3 lines of defense of gastric mucosa:
- Mucous layer that forms protective pH gradient
- Surface epithelial cells that can repair small defects
- Postepithelial barrier that neutralizes any acid that has traversed first 2 layers
- No definite link between histologic gastritis and dyspeptic symptoms
- Epithelial cell damage with no associated inflammation - “gastropathy”
Etiology
- Common causes of gastritis: Infections, autoimmune, drugs (i.e., cocaine), hypersensitivity, stress
- Common causes of gastropathy: Endogenous or exogenous irritants, such as bile reflux, alcohol, or aspirin and NSAIDs, ischemia, stress, chronic congestion
- Acute gastritis:
- Stress (sepsis, burns, trauma):
- Decrease in splanchnic blood flow leading to decreased mucus production, bicarbonate secretion, and prostagland in synthesis
- Results in mucosal erosions and hemorrhage
- Alcohol:
- Induces production of leukotrienes that cause microvascular stasis, engorgement, and increased vascular permeability
- Leads to hemorrhage
- NSAIDs, including aspirin:
- Interfere with prostagland in synthesis, leading to similar cascade as induced by alcohol
- Results in mucosal erosions
- Steroids
- Chronic gastritis:
- Produced by Helicobacter pylori
- Mechanism of H. pylori unclear:
- Gram-negative spiral bacteria found in gastric mucous layer
- Contains enzyme urease that allows it to change pH level (alkaline) of its microenvironment
Signs and Symptoms
- Dyspepsia
- Bloating
- Nausea/vomiting
- Vomiting coffee grounds/blood
- Melena
- Anorexia
- Epigastric tenderness
- Heartburn
History
- Dyspepsia
- Epigastric pain or discomfort (episodic and chronic)
- Bloating, indigestion, eructation, flatulence, and heartburn
- Anorexia, nausea/vomiting
- Hematemesis, melena
Physical Exam
- Careful physical exam including stool hemoccult testing and vital signs with orthostatics
- Dehydration, tachycardia (with vomiting)
- Pallor (hemorrhagic gastritis)
- Abdominal exam
- Nonspecific
- Epigastric tenderness
Essential Workup
- ABCs
- Hematocrit determination
- Evaluation for dehydration/shock
Diagnostic Tests & Interpretation
Lab
- Normal lab values in uncomplicated gastritis
- CBC:
- Anemia with acute hemorrhagic gastritis
- Leukocytosis: Infection
- Electrolytes, BUN, creatinine, glucose
- Lipase for pancreatitis in differential
- Urinalysis:
- Assess dehydration/ketosis (starvation)
- Bilirubin present with hepatitis
Diagnostic Procedures/Surgery
- ECG:
- For elderly patients
- Myocardial ischemia in differential
- Endoscopy:
- Outpatient unless significant hemorrhage
- Allows for visualization of bleeding sites, histologic confirmation of mucosal inflammation, and detection of H. pylori
- Noninvasive H. pylori testing:
- 13C and 14C urea breath tests
- Stool antigen test
- Serology to detect antibodies to H. pylori
- Serum pepsinogen isoenzymes:
- The ratio of pepsinogen isozymes I and II in serum correlates with presence of metaplastic atrophic gastritis (principally autoimmune metaplastic atrophic gastritis and pernicious anemia)
Differential Diagnosis
- Peptic ulcer disease (PUD)
- Nonulcer dyspepsia (symptoms without ulcer on endoscopy)
- Gastroesophageal reflux
- Biliary colic
- Cholecystitis
- Pancreatitis
- Hepatitis
- Abdominal aortic aneurysm
- Aortic dissection
- Myocardial infarction
Prehospital
- ABCs
- IV fluid resuscitation
Initial Stabilization/Therapy
- ABCs with acute erosive or hemorrhagic gastritis that presents with hemodynamic instability
- IV fluid resuscitation with lactated Ringer solution or 0.9% normal saline (NS) via 2 large-bore catheters
- NGT for gastric decompression and lavage when history of hematemesis or unstable vital signs
- Foley catheterization to assess volume replacement
ED Treatment/Procedures
- Pain control with:
- Antacids
- GI cocktail:
- 30 mL antacids + 10-20 mL 2% viscous lidocaine
- H2 antagonists
- Proton pump inhibitors (PPIs)
- Sucralfate
- Avoid narcotics - may mask serious illness
- Acute hemorrhagic gastritis:
- IV fluid resuscitation
- Blood transfusion if low hematocrit
- Reverse causes (alcohol, sepsis, NSAIDs, or trauma)
- Prevent acute or erosive gastritis in critically ill:
- IV PPI or H2 antagonists
- Goal is to keep pH level at >4
- Chronic gastritis - H. pylori therapy:
- Treatment of H. pylori infection:
- Invasive or noninvasive testing to confirm infection
- Oral (PO) eradication antibiotic therapy options
- Treatment controversial for asymptomatic or nonulcer dyspepsia gastritis
- Vitamin B12 supplementation for atrophic gastritis
Medication
- Bismuth subsalicylate: 525-mg tabs 2 PO q.i.d not to exceed 8 doses in 24 hr
- Cimetidine (H2 blocker): 800 mg PO at bedtime (peds: 20-40 mg/kg/24 hr) for 6-8 wk
- Famotidine (H2 blocker): 40 mg PO at bedtime (peds: 0.5-0.6 mg/kg q12h) for 6-8 wk
- Lansoprazole (PPI): 30 mg PO b.i.d for 2 wk
- Maalox Plus: 2-4 tabs PO q.i.d
- Misoprostol: 100-200 mcg PO q.i.d
- Mylanta II: 2-4 tabs PO q.i.d
- Nizatidine (H2 blocker): 300 mg PO at bedtime for 6-8 wk
- Omeprazole (PPI): 20 mg PO b.i.d (peds: 0.6-0.7 mg/kg q12-24 h) for 2 wk
- Pantoprazole (PPI): 40 mg PO/IV daily for 2 wk
- Ranitidine (H2 blocker): 300 mg PO at bedtime (peds: 5-10 mg/kg/24 hr given q12h) for 6-8 wk
- Sucralfate: 1 g PO q.i.d for 6-8 wk
First Line
- Clarithromycin triple therapy:
- Sequential 10-d therapy in high-prevalence areas
- Double therapy for 5 d:
- PPI twice daily
- Amoxicillin (1 g)
- Followed by triple therapy for 5 d:
- PPI twice daily
- Clarithromycin (500 mg) twice daily
- Metronidazole (500 mg) 3 times daily
- Bismuth-based quadruple therapies
- PPI (stand ard dose)
- Bismuth subcitrate (120-300 mg, or 420 mg) or bismuth subsalicylate (300 or 524 mg) 4× daily
- Tetracycline (500 mg) 4× daily
- Metronidazole (500 mg) 3× daily
- Concomitant therapy 10/14 d
- PPI twice daily
- Clarithromycin (500 mg) and amoxicillin (1 g) or metronidazole (500 mg) given twice daily
- Hybrid therapy
- PPI twice daily plus amoxicillin (1 gm) twice daily for 5 d, followed by:
- PPI, clarithromycin (500 mg), amoxicillin (500 mg) plus metronidazole (500 mg) or tinidazole (500 mg) given twice daily for 7 d
- Levofloxacin sequential therapy
- PPI twice daily plus amoxicillin (1 gm) twice daily for 5-7 d, followed by:
- PPI, Levofloxacin (500 mg) once daily, Amoxicillin (500 mg) twice daily, plus Metronidazole or Tinidazole (500 mg) given twice daily for 5-7 d
- The rescue treatment should be based on antimicrobial susceptibility testing
Disposition
Admission Criteria
- Acute hemorrhagic or erosive gastritis that presents with upper GI tract bleeding, tachycardia, and hypotension
- Uncontrolled pain or vomiting
- Coagulopathy from medication or liver disease
Discharge Criteria
- Unremarkable physical exam with normal CBC and heme-negative stools
- If heme-positive stools, discharge if stable vital signs, normal hematocrit, and negative NGT aspiration for upper GI tract hemorrhage:
- Outpatient evaluation for endoscopy
Issues for Referral
- Outpatient referral for endoscopy and H. pylori testing
- Biopsy for gastric dysplasia and malignancy
Follow-up Recommendations
Close follow-up with gastroenterologist for endoscopy with biopsy for diagnostic reasons
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