Gastritis: Clinical sciences

Gastritis, or inflammation of the gastric mucosa, is typically associated with excessive acid production, which can eventually lead to erosions and ulcerations of the stomach lining, destruction of the glandular layer of the stomach, and fibrosis. Based on the duration of symptoms, gastritis can be classified as acute, persistent, and chronic. Acute and persistent gastritis last less than 30 days and include stress-, chemical-, and infectious gastritis. On the other hand, chronic gastritis persists for more than 30 days and includes autoimmune-, H. Pylori, and reactive gastritis.

Now, if a patient presents with chief concerns suggesting gastritis, first obtain a focused history and physical exam as well as labs, including CBC and fecal occult blood test. These patients will report upper abdominal pain, indigestion, and, in some cases, symptoms like nausea, vomiting, and bloating. The physical exam may reveal epigastric tenderness and halitosis, as well as signs of pallor and tachycardia. Moreover, pallor and tachycardia are signs of anemia, which occurs when inflammation of gastric mucosa results in mucosal erosions, ulcers, and subsequent bleeding. So, keep in mind that, in some individuals, labs might reveal anemia or a positive fecal occult blood test. If your patient presents with these findings, suspect gastritis and assess the duration of symptoms.

Symptoms that last 30 days or less are suggestive of acute- or persistent gastritis. Moreover, symptoms of acute gastritis last 14 days or less, while symptoms of persistent gastritis last from 15 to 30 days. Both types are associated with the same conditions, so your next step is to assess the underlying cause. First, review the patient’s history and physical exam findings and be sure to order esophagogastroduodenoscopy or EGD for short, to visualize gastric mucosa, and if needed, take biopsy samples. Additionally, if you suspect infectious gastritis, don’t forget to order relevant microbiology testing for bacteria, viruses, fungi, and parasites associated with gastritis.

First let’s discuss stress gastritis! In this case, the patient will report a stressful physiological event, such as trauma, shock, sepsis, or surgery, while the EGD will reveal superficial erythematous mucosal erosions. With these findings, diagnose stress gastritis and proceed with treatment, which includes medications for acid suppression, such as proton pump inhibitors or H2 blockers. Keep in mind that you should also use these medications as prophylaxis in critically ill patients to prevent stress gastritis and potentially life-threatening complications, like gastric hemorrhage, perforation, and sepsis.

Next up is chemical gastritis! These individuals will report exposure to certain medications, including NSAIDs or corticosteroids, or they might report excessive alcohol consumption. Next, EGD will show subepithelial hemorrhages, erosions, and ulcers of gastric mucosa, while the biopsy will reveal foveolar hyperplasia with mucin depletion and serrated gastric pits. With these findings, diagnose chemical gastritis! Treatment primarily relies on removing the offending irritant, but you can also consider acid suppression with proton pump inhibitors or H2 blockers.

Let’s move on to infectious gastritis! In this case, the patient might report symptoms of infection, like fever, malaise, and fullness; and the microbiology testing might identify a specific pathogen. Next, the EGD will show erythema, nodular mucosa, or ulceration, while the biopsy will reveal apoptotic cells in the mucosa and, in some cases, gland abscesses. In this case, diagnose infectious gastritis and proceed with treatment, which includes treating the underlying pathogen with or without proton pump inhibitors or H2 blockers for acid suppression.

Now, let’s go back and look at individuals reporting that their symptoms have lasted for over 30 days. These findings are suggestive of chronic gastritis, so your next step is to assess the underlying cause.

First, let’s take a look at autoimmune gastritis! In this case, your patient might report neurological symptoms, including tingling, lower extremity weakness, and cognitive changes. Also, there might be a history of autoimmune conditions, like Hashimoto thyroiditis and Addison disease. At this point, suspect autoimmune gastritis and order additional labs, including anti-parietal cell- and anti-intrinsic factor antibodies, as well as gastrin, pepsinogen, iron, and vitamin B12 levels. Finally, be sure to visualize the gastric mucosa using EGD and don’t forget to take biopsy samples.