Gastritis: Clinical sciences

Chapters:

Watch video only

Introduction0:00–0:46

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.

Focused H&P0:46–1:47

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.

Acute/Persistent gastritis1:47–2:37

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.

Stress gastritis2:37–3:22

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.

Chemical gastritis3:22–4:03

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.

Infectious gastritis4:03–4:45

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.

Chronic gastritis4:45–5:01

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.

Autoimmune gastritis5:01–8:09

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. In autoimmune gastritis, anti-parietal cell and anti-intrinsic factor antibodies might be positive.
Moreover, anti-parietal cell antibodies stimulate the immune system to destroy acid-producing parietal cells of gastric mucosa, eventually decreasing the production of hydrochloric acid and causing hypochlorhydria.
As a result, the body will try to stimulate hydrochloric acid production by secreting more gastrin, so the labs will reveal elevated gastrin levels.
Additionally, gastric damage will affect chief cells, which normally secrete pepsinogen. In other words, your patient will have low pepsinogen levels.
Next, hypochlorhydria can affect iron absorption, so your patient might present with low iron levels and iron deficiency.
Finally, if anti-intrinsic factor antibodies are positive, there will not be enough intrinsic factor, which will result in impaired vitamin B12 absorption and pernicious anemia.
Now, here’s a high-yield fact to keep in mind! Pernicious anemia is a late manifestation of autoimmune gastritis characterized by neurological findings because vitamin B12 is crucial for normal functioning of the nervous system.
These patients will often present with clinical features, like decreased sensation, diminished reflexes, ataxia, and a positive Romberg test.
Next, the EGD will show mucosal erythema, nodularity, and atrophic changes of gastric mucosa; while the biopsy will reveal diffuse or multifocal lymphoplasmacytic infiltrates, glandular atrophy, and loss of parietal cells.
With these findings, diagnose autoimmune gastritis and initiate acid suppression with proton pump inhibitors and H2 blockers.
Also, encourage dietary modification by avoiding triggers, like alcohol, coffee, and tobacco; and eating small frequent meals low in fat and acid.
Finally, recommend lifestyle modifications, including stress reduction, smoking cessation, and weight management. Next up is H.

H. Pylori Gastritis8:09–9:46

pylori gastritis, which might be associated with symptoms like loss of appetite, frequent belching, and unintentional weight loss.
With this clinical picture, suspect H. pylori gastritis, so consider noninvasive H.
pylori testing, like urea breath test, H. pylori stool antigen test, or H.
pylori serology. However, you should also obtain the EGD with biopsy, which includes the invasive H.
Pylori rapid urease test, culture, and PCR. In some cases, noninvasive H.
pylori testing might be positive, but sometimes, the results might come back negative as well. Regardless of noninvasive testing results, if the EGD shows hyperemia, enlargement of mucosal folds, mucosal nodularity, and fundic gland polyps; and biopsy is positive for H.
pylori, diagnose H. pylori gastritis.
In this case, prescribe triple therapy for 14 days, which includes a proton pump inhibitor, clarithromycin, and amoxicillin or metronidazole.
Here's a high-yield fact! H.
pylori is a gram-negative bacterium that affects up to 50% of the population worldwide. It is the most common cause of chronic gastritis, peptic ulcer disease, gastric lymphoma, and gastric carcinoma.

Reactive gastritis9:46–10:49

Finally, let’s look at reactive gastritis, which is often associated with long-term NSAID use, alcohol consumption, or bile reflux.
With this clinical picture, suspect reactive gastritis and proceed with EGD with biopsy. The endoscopy might be normal or show mucosal erythema, edema, or erosions.
However, if the biopsy reveals foveolar hyperplasia and elongation and tortuosity of the gastric folds with a corkscrew appearance, diagnose reactive gastritis.
Treatment includes lifestyle modification by removing irritants such as alcohol and NSAIDs. Your patient might need medical therapy, including proton pump inhibitors and H2 blockers for acid suppression, as well as sucralfate and ursodeoxycholic acid to relieve symptoms like abdominal pain and nausea.
Alright, as a quick recap… Gastritis refers to inflammation of the gastric mucosa, which can be categorized as acute, persistent, or chronic gastritis.

Review10:49–11:47

Acute and persistent gastritis lasts for less than 30 days and is caused by stress gastritis, chemical gastritis, and infectious gastritis.
Treatment includes acid suppression with proton pump inhibitors and H2 blockers, removing the offending chemical, and treating the underlying infection.
On the other hand, chronic gastritis lasts for more than 30 days and includes autoimmune gastritis, H. pylori gastritis, and reactive gastritis.
Treatment includes a combination of lifestyle modification, dietary modification, and medical therapy including proton pump inhibitors, H2 blockers, and antibiotics depending