Gastritis

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Basics

Description

  • Inflammation of the gastric mucosa
  • Can be classified by time course (acute vs. chronic)
    • Acute: Neutrophilic infiltration on histology
    • Chronic: Mixture of mononuclear cells, lymphocytes, macrophages on histology
  • Multiple types of gastritis have been described. There is no universally accepted classification for gastritis.
  • Subtypes of gastritis include:
    • Erosive gastritis or reactive gastropathy
      • Mucosal injury by a noxious agent (especially nonsteroidal anti-inflammatory drugs [NSAIDs] or alcohol) or vascular congestion and/or mucosal ischemia
      • Damage to the surface epithelium caused by mucosal hypoxia or the direct action of NSAIDs with no associated inflammation
    • Reflux gastritis
      • A reaction to protracted reflux exposure to biliary and pancreatic fluid
      • Typically limited to the prepyloric antrum
    • Hemorrhagic gastritis (stress ulceration)
      • A reaction to hemodynamic disorder (e.g., hypovolemia or hypoxia [shock])
      • Common in intensive care unit (ICU) patients, particularly after severe burns and trauma
      • Seen rarely with certain medications (e.g., dabigatran, an oral thrombin inhibitor
    • Infectious gastritis
      • Acute and/or chronic Helicobacter pylori infection (most common cause of gastritis)
      • Viral infection (reaction to systemic infection)
      • Phlegmonous gastritis
    • Atrophic gastritis
      • Autoimmune versus environmental
      • Frequent in the elderly
      • Primarily from long-standing H. pylori infections
      • Prolonged proton pump inhibitor (PPI) use
      • Major risk factor for gastric cancer
      • Associated with primary (pernicious) anemia

Geriatric Considerations
Persons age >60 years often harbor H. pylori infection.

Pediatric Considerations
Gastritis rarely occurs in infants or children; increases in prevalence with age.

Epidemiology

  • Predominant age: all adult ages (more common in elderly)
  • Predominant sex: male = female

Incidence
Accounts for 1.8–2.1 million medical visits each year in the United States

Prevalence
  • Gastritis is more prevalent in those >60 years of age
    • Prevalence of 50-60% by age 60
  • ~30–35% of U.S. adults are infected with H. pylori
    • Rates of infection are higher in minority groups and immigrants
    • Prevalence also higher in lower socioeconomic status

Etiology and Pathophysiology

  • Noxious agents cause a breakdown in the gastric mucosal barrier, exposing epithelium to injury.
  • Infection: H. pylori (most common cause), Staphylococcus aureus exotoxins, and viral infections
  • Alcohol
  • Aspirin and other NSAIDs
  • Bile reflux
  • Pancreatic enzyme reflux
  • Portal hypertensive gastropathy
  • Emotional stress
  • Hemodynamic instability (hypoxemia)

Genetics
Unknown, but observational studies show that 10% of a given population is never colonized with H. pylori, regardless of exposure. Genetic variations in TLR1 may help explain some of this observed variation in individual risk for H. pylori infection.

Risk Factors

  • Age >60 years
  • Exposure to potentially noxious drugs or chemicals (e.g., alcohol or NSAIDs)
  • Hypovolemia, hypoxia (shock), burns, head injury, complicated postoperative course
  • Autoimmune diseases (thyroid disease and diabetes)
  • Family history of H. pylori and/or gastric cancer
  • Stress (hypovolemia or hypoxia)
  • Tobacco use
  • Radiation
  • Ischemia
  • Pernicious anemia
  • Gastric mucosal atrophy

General Prevention

  • Avoid injurious drugs or chemical agents including but not limited to alcohol and tobacco.
  • Patients with hypovolemia or hypoxia (especially ICU patients) should receive prophylaxis with H2 receptor antagonists, proton pump inhibitors, prostaglandins, or sucralfate.
  • Consider testing for H. pylori (and eradicating if present) in patients on long-term NSAID therapy.

Commonly Associated Conditions

  • Gastric or duodenal peptic ulcer
  • Primary (pernicious) anemia—atrophic gastritis
  • Portal hypertension (HTN), hepatic failure
  • Mucosa-associated lymphoid tissue (MALT) lymphoma

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Basics

Description

  • Inflammation of the gastric mucosa
  • Can be classified by time course (acute vs. chronic)
    • Acute: Neutrophilic infiltration on histology
    • Chronic: Mixture of mononuclear cells, lymphocytes, macrophages on histology
  • Multiple types of gastritis have been described. There is no universally accepted classification for gastritis.
  • Subtypes of gastritis include:
    • Erosive gastritis or reactive gastropathy
      • Mucosal injury by a noxious agent (especially nonsteroidal anti-inflammatory drugs [NSAIDs] or alcohol) or vascular congestion and/or mucosal ischemia
      • Damage to the surface epithelium caused by mucosal hypoxia or the direct action of NSAIDs with no associated inflammation
    • Reflux gastritis
      • A reaction to protracted reflux exposure to biliary and pancreatic fluid
      • Typically limited to the prepyloric antrum
    • Hemorrhagic gastritis (stress ulceration)
      • A reaction to hemodynamic disorder (e.g., hypovolemia or hypoxia [shock])
      • Common in intensive care unit (ICU) patients, particularly after severe burns and trauma
      • Seen rarely with certain medications (e.g., dabigatran, an oral thrombin inhibitor
    • Infectious gastritis
      • Acute and/or chronic Helicobacter pylori infection (most common cause of gastritis)
      • Viral infection (reaction to systemic infection)
      • Phlegmonous gastritis
    • Atrophic gastritis
      • Autoimmune versus environmental
      • Frequent in the elderly
      • Primarily from long-standing H. pylori infections
      • Prolonged proton pump inhibitor (PPI) use
      • Major risk factor for gastric cancer
      • Associated with primary (pernicious) anemia

Geriatric Considerations
Persons age >60 years often harbor H. pylori infection.

Pediatric Considerations
Gastritis rarely occurs in infants or children; increases in prevalence with age.

Epidemiology

  • Predominant age: all adult ages (more common in elderly)
  • Predominant sex: male = female

Incidence
Accounts for 1.8–2.1 million medical visits each year in the United States

Prevalence
  • Gastritis is more prevalent in those >60 years of age
    • Prevalence of 50-60% by age 60
  • ~30–35% of U.S. adults are infected with H. pylori
    • Rates of infection are higher in minority groups and immigrants
    • Prevalence also higher in lower socioeconomic status

Etiology and Pathophysiology

  • Noxious agents cause a breakdown in the gastric mucosal barrier, exposing epithelium to injury.
  • Infection: H. pylori (most common cause), Staphylococcus aureus exotoxins, and viral infections
  • Alcohol
  • Aspirin and other NSAIDs
  • Bile reflux
  • Pancreatic enzyme reflux
  • Portal hypertensive gastropathy
  • Emotional stress
  • Hemodynamic instability (hypoxemia)

Genetics
Unknown, but observational studies show that 10% of a given population is never colonized with H. pylori, regardless of exposure. Genetic variations in TLR1 may help explain some of this observed variation in individual risk for H. pylori infection.

Risk Factors

  • Age >60 years
  • Exposure to potentially noxious drugs or chemicals (e.g., alcohol or NSAIDs)
  • Hypovolemia, hypoxia (shock), burns, head injury, complicated postoperative course
  • Autoimmune diseases (thyroid disease and diabetes)
  • Family history of H. pylori and/or gastric cancer
  • Stress (hypovolemia or hypoxia)
  • Tobacco use
  • Radiation
  • Ischemia
  • Pernicious anemia
  • Gastric mucosal atrophy

General Prevention

  • Avoid injurious drugs or chemical agents including but not limited to alcohol and tobacco.
  • Patients with hypovolemia or hypoxia (especially ICU patients) should receive prophylaxis with H2 receptor antagonists, proton pump inhibitors, prostaglandins, or sucralfate.
  • Consider testing for H. pylori (and eradicating if present) in patients on long-term NSAID therapy.

Commonly Associated Conditions

  • Gastric or duodenal peptic ulcer
  • Primary (pernicious) anemia—atrophic gastritis
  • Portal hypertension (HTN), hepatic failure
  • Mucosa-associated lymphoid tissue (MALT) lymphoma

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