GastritisGastritis

Michał Holecki, MD, PhDMichał Holecki, MD, PhDDepartment of PathophysiologyDepartment of Pathophysiology

Gastritis includes a myriad of disorders that involve inflammatory changes in the gastric mucosa, including:

1. erosive gastritis caused by a noxious irritant

2. reflux gastritis from exposure to bile and pancreatic fluids

3. hemorrhagic gastritis

4. infectious gastritis

5. gastric mucosal atrophy

Acute gastritisAcute gastritis

an acute mucosal inflammatory process, usually of an acute mucosal inflammatory process, usually of a transient naturea transient nature

severe erosive form is an important cause of acute severe erosive form is an important cause of acute gastrointestinal bleedinggastrointestinal bleeding

PathophysiologPathophysiologyy

The mechanisms of mucosal injury in gastritis and PUD The mechanisms of mucosal injury in gastritis and PUD are thought to be an imbalance of are thought to be an imbalance of

aggressive factorsaggressive factors

acid production or pepsinacid production or pepsin

and and defensive factorsdefensive factors mucus production mucus production bicarbonate bicarbonate and blood flowand blood flow

PathophysiologPathophysiologyy

Erosive gastritisErosive gastritis usually is associated with serious usually is associated with serious illness or with various drugs. illness or with various drugs.

Stress, ethanol, bile, and nonsteroidal anti-Stress, ethanol, bile, and nonsteroidal anti-inflammatory drugs (NSAIDs) disrupt the gastric inflammatory drugs (NSAIDs) disrupt the gastric mucosal barrier, making it vulnerable to normal mucosal barrier, making it vulnerable to normal

gastric secretions.gastric secretions.

PathophysiologPathophysiologyy

NSAIDsNSAIDs and aspirin also interfere with the and aspirin also interfere with the protective mucus layer by protective mucus layer by inhibiting mucosal inhibiting mucosal cyclooxygenase activitycyclooxygenase activity, reducing levels of , reducing levels of

mucosal prostaglandinsmucosal prostaglandins

Sex: Sex:

Male-to-female ratio of gastritis is Male-to-female ratio of gastritis is approximately 1:1approximately 1:1

Male-to-female ratio of PUD is Male-to-female ratio of PUD is approximately 2:1approximately 2:1

Age: Age:

An estimated 60% of Americans older than 60 An estimated 60% of Americans older than 60 years harbor years harbor H pyloriH pylori..

Duodenal ulcers usually occur in those aged 25-Duodenal ulcers usually occur in those aged 25-75 years.75 years.

Gastric ulcer incidence peaks in those aged 55-65 Gastric ulcer incidence peaks in those aged 55-65

yearsyears..

Acute gastritisAcute gastritis

AAcute gastritiscute gastritis

AAcute hemorrhagic gastritiscute hemorrhagic gastritis

AAcute erosive gastritiscute erosive gastritis

AAcute stress gastritiscute stress gastritis

Patients typically present with abdominal pain Patients typically present with abdominal pain

that has the following characteristicsthat has the following characteristics Epigastric to left upper quadrantEpigastric to left upper quadrant

Frequently described as burningFrequently described as burning

May radiate to the backMay radiate to the back

Usually occurs 1-5 hours after mealsUsually occurs 1-5 hours after meals

May be relieved by food, antacids (duodenal), or vomiting (gastric)May be relieved by food, antacids (duodenal), or vomiting (gastric)

Typically follows a daily pattern specific to patientTypically follows a daily pattern specific to patient

PhysicaPhysicall

Epigastric tenderness is present and usually mild.Epigastric tenderness is present and usually mild.

Bowel sounds are normal.Bowel sounds are normal.

Signs of peritonitis or GI bleeding may manifest. Signs of peritonitis or GI bleeding may manifest. ((Perform a rectal examination and Hemoccult Perform a rectal examination and Hemoccult

testingtesting))

CausesCauses H pyloriH pylori (most common cause of ulceration) (most common cause of ulceration) NSAIDs, aspirinNSAIDs, aspirin Gastrinoma (Zollinger-Ellison syndrome)Gastrinoma (Zollinger-Ellison syndrome) Severe stress (eg, trauma, burns), Curling ulcersSevere stress (eg, trauma, burns), Curling ulcers AlcoholAlcohol Bile refluxBile reflux Pancreatic enzyme refluxPancreatic enzyme reflux RadiationRadiation Staphylococcus aureusStaphylococcus aureus exotoxin exotoxin Bacterial or viral infectionBacterial or viral infection

Differential diagnosisDifferential diagnosis

   Acute Coronary Syndrome Acute Coronary Syndrome

[Aneurysms, Abdominal][Aneurysms, Abdominal]CholangitisCholangitis CholecystitisCholecystitis and and BiliaryBiliary Colic Colic CholelithiasisCholelithiasis Diverticular Disease Diverticular Disease Esophagitis Esophagitis Gastroenteritis Gastroenteritis Hepatitis Hepatitis Inflammatory Bowel DiseaseInflammatory Bowel Disease

Differential diagnosisDifferential diagnosis

Mesenteric Ischemia Mesenteric Ischemia

Myocardial Infarction Myocardial Infarction

Pancreatitis Pancreatitis

Pulmonary Embolism Pulmonary Embolism

Renal CalculiRenal Calculi

Other Problems to be Considered: Other Problems to be Considered:

Gastric cancerGastric cancer

Esophageal varicesEsophageal varicesMallory-Weiss tearsMallory-Weiss tearsAtrophic gastritisAtrophic gastritisNonulcer dyspepsiaNonulcer dyspepsiaFunctional gastrointestinal disorderFunctional gastrointestinal disorder

Atypical appendicitis in the pregnant patientAtypical appendicitis in the pregnant patient

Complications:Complications:

MalignancyMalignancy

HemorrhageHemorrhage

PerforationPerforation

ObstructionObstruction

•Patients should be warned of known or potentially injurious drugs and agents. Some examples are as follows:

o NSAIDs

o Aspirin

o Alcohol

• Caffeine (eg, coffee, tea, colas)

Chronic gastritisChronic gastritis

Type A [fundal] gastritisType A [fundal] gastritis

Type B [antral] gastritisType B [antral] gastritis

[a][a] hypersecretory gastritis hypersecretory gastritis

[b][b] environmental gastritis.environmental gastritis.

Hypertrophic gastritisHypertrophic gastritis

Type A [fundal] gastritisType A [fundal] gastritis

circulating antibodies to parietal cells and intrinsic factor circulating antibodies to parietal cells and intrinsic factor

hypo- or achlorhydriahypo- or achlorhydria

a high intragastric pH and hypergastrinemia a high intragastric pH and hypergastrinemia

10% of patients go on develop overt pernicious anemia 10% of patients go on develop overt pernicious anemia

associated with autoimmune disorders such as associated with autoimmune disorders such as Hashimoto’s thyroiditis and Adison’s diseaseHashimoto’s thyroiditis and Adison’s disease

Type B [antral] gastritisType B [antral] gastritis

the hypersecretory typethe hypersecretory type - restricted to the antrum - restricted to the antrum - gastric hypersecretion - gastric hypersecretion - frequently symptomatic - frequently symptomatic

the environmental gastritisthe environmental gastritis - the most common form of gastritis in all age groups - the most common form of gastritis in all age groups - irregularly focal involvment of the antral mucosa - irregularly focal involvment of the antral mucosa

- gradually extends deeper into the mucosa and cause mucosal atrophy- gradually extends deeper into the mucosa and cause mucosal atrophy

Hypertrophic gastritisHypertrophic gastritis

Three variants are recognizedThree variants are recognized

Menetrier’s diseaseMenetrier’s disease

Hypersecretory gastropathyHypersecretory gastropathy

GGastric gland hyperplasiaastric gland hyperplasia

[[the Zollinger-Ellison syndromethe Zollinger-Ellison syndrome]]

All three types are characterized by giant cerebriform enlargement of the rugal folds of the gastric mucosa

SStress ulcerstress ulcers ShockShock

EExtensive burnsxtensive burns

SepsisSepsis

TraumaTrauma

BBrain tumors and following intracranial surgeryrain tumors and following intracranial surgery

Etiology of stress Etiology of stress ulcersulcers

Neurogenic or catecholamine-induced vasoconstriction

Mucosal ischemia

Damage the mucosal barrier

Directly injure mucosal cells by oxygen or metabolic deprivation

SStress ulcerstress ulcers

Those associated with intracranial problems are Those associated with intracranial problems are referred to as referred to as Cushing’s ulcers.Cushing’s ulcers.

Those associated with shock an extensive burns Those associated with shock an extensive burns are referred to as are referred to as Curling’s ulcersCurling’s ulcers..