The Stomach

GASTRITIS
What is Gastritis?

An inflammation, irritation or erosion of the

stomach lining. Can be of acute or a chronic
complaint.
Acute gastritis often due to chemical injury
(alcohol/drugs)
Chronic gastritis: H. Pylori infection,
chemical, autoimmune.
 What Causes Gastritis?
Bile reflux Drugs
NSAIDs, such as aspirin, ibuprofen, and naproxen
Cocaine
Iron
Colchicine, when at toxic levels, as in patients with failing renal or
hepatic function
Kayexalate
Chemotherapeutic agents, such as mitomycin C, 5-fluoro-2-
deoxyuridine, and floxuridine
Potent alcoholic beverages, such as whisky, vodka, and gin
Bacterial infections
H pylori (most frequent)
H heilmanii (rare)
Streptococci (rare)
Viral infections (eg, CMV)
 Fungal infections
Candidiasis
Histoplasmosis
Phycomycosis
Parasitic infection (eg, anisakidosis)
Acute stress (shock)
Radiation
Allergy and food poisoning
Spicy food
Smoking
Bile: The reflux of bile (an alkaline medium important for the
activation of digestive enzymes in the small intestine) from
the small intestine to the stomach can induce gastritis.
Ischemia: This term is used to refer to damage induced by
decreased blood supply to the stomach. This rare etiology is
due to the rich blood supply to the stomach.
Direct trauma
 Acute
Acute gastritis is a term covering a broad
spectrum of entities that induce inflammatory
changes in the gastric mucosa.
The different etiologies share the same general
clinical presentation. However, they differ in
their unique histologic characteristics.
The inflammation may involve the entire
stomach (eg, pangastritis) or a region of the
stomach (eg, antral gastritis).
Acute gastritis can be broken down into 2
categories: erosive (eg, superficial erosions, deep
erosions, hemorrhagic erosions) and nonerosive
(generally caused by Helicobacter pylori).
Erosive Gastritis

Acute erosive gastritis can result from the exposure

to a variety of agents or factors. This is referred to as
reactive gastritis.
These agents/factors include nonsteroidal anti-
inflammatory medications (NSAIDs), alcohol,
cocaine, stress, radiation, bile reflux, and ischemia.
The gastric mucosa exhibits hemorrhages, erosions,
and ulcers. NSAIDs, such as aspirin, ibuprofen, and
naproxen, are the most common agents associated
with acute erosive gastritis.
This results from oral or systemic administration of
these agents either in therapeutic doses or in
supratherapeutic doses.
Chronic

The ABC in chronic Gastritis:

A Autoimmune
B Bacterial (H. Pylori)
C Chemical (NSAIDs)
Chronic noninfectious granulomatous gastritis
Lymphocytic gastritis
Eosinophilic gastritis
Ischemic gastritis
Radiation gastritis
 Autoimmune Gastritis
This type of gastritis is associated with serum
antiparietal and anti-intrinsic factor (IF)
antibodies.
The gastric corpus undergoes progressive
atrophy, IF deficiency occurs, and patients may
develop pernicious anemia.
Autoantibodies are directed against at least 3
antigens, including IF, cytoplasmic (microsomal-
canalicular), and plasma membrane antigens.
Two types of IF antibodies are detected, ie, types I
and II. Type I IF antibodies block the IF-cobalamin
binding site, thus preventing the uptake of
vitamin B-12. Cell-mediated immunity also
contributes to the disease.
T-cell lymphocytes infiltrate the gastric mucosa
and contribute to epithelial cell destruction and
resulting gastric atrophy.
 H. pylori
The corkscrew-shaped bacterium called H
pylori is the most common cause of
gastritis.
Complications result from a chronic
infection rather than from an acute
infection.
The prevalence of H pylori in otherwise
healthy individuals varies depending on
age, socioeconomic class, and country of
origin.
In the Western world, the number of
people infected with H pylori increases
with age.
Evidence of H pylori infection can be found H pylori gastritis typically starts as an
acute gastritis in the antrum, causing
in 20% of individuals younger than 40
intense inflammation, and over time, it
years and in 50% of individuals older than may extend to involve the entire gastric
60 years. mucosa resulting in chronic gastritis.
 Tuberculosis is a rare cause of gastritis, but an increasing number of cases have
developed because of patients who are immunocompromised. Gastritis caused by
tuberculosis is generally associated with pulmonary or disseminated disease.
Secondary syphilis of the stomach is a rare cause of gastritis.
Phlegmonous gastritis is an uncommon form of gastritis caused by numerous bacterial
agents, including streptococci, staphylococci, Proteus species, Clostridium species, and
Escherichia coli.
Viral infections can cause gastritis. Cytomegalovirus (CMV) is a common viral cause of
gastritis. It is usually encountered in individuals who are immunocompromised,
including those with cancer, immunosuppression, transplants, and AIDS. Gastric
involvement can be localized or diffuse.
Fungal infections that cause gastritis include Candida albicans and histoplasmosis. The
common predisposing factor is immunosuppression. C albicans rarely involves the
gastric mucosa.
Parasitic infections are rare causes of gastritis. Anisakidosis is caused by a nematode
that embeds itself in the gastric mucosa along the greater curvature. Anisakidosis is
acquired by eating contaminated sushi and other types of contaminated raw fish. It
often causes severe abdominal pain that subsides within a few days. This nematode
infection is associated with gastric fold swelling, erosions, and ulcers.
Ulcero-hemorrhagic gastritis is most commonly seen in patients who are critically ill.
Ulcero-hemorrhagic gastritis is believed to be secondary to ischemia related to
hypotension and shock or to the release of vasoconstrictive substances, but the
etiology is often unknown.
Microscopic evidence of acute gastritis can be seen in patients with Crohn disease,
though clinical manifestations are rare (occurring in only about 2-7% of patients with
Crohn disease).
Chemical Gastritis
This type of gastritis is associated with long-term intake of aspirin or
NSAIDs.
It also develops when bile-containing intestinal contents reflux into the
stomach.
Although bile reflux may occur in the intact stomach, most of the
features associated with bile reflux are typically found in patients with
partial gastrectomy, in whom the lesions develop near the surgical
stoma.
The mechanisms through which bile alters the gastric epithelium involve
the effect of several bile constituents. Both lysolecithin and bile acids
can disrupt the gastric mucous barrier, allowing the back diffusion of
positive hydrogen ions and resulting in cellular injury.
Pancreatic juice enhances epithelial injury in addition to bile acids. In
contrast to other chronic gastropathies, minimal inflammation of the
gastric mucosa typically occurs in chemical gastropathy.
Chronic noninfectious
granulomatous gastritis
Noninfectious diseases are the usual cause of
gastric granulomas and include Crohn disease,
sarcoidosis, and isolated granulomatous
gastritis.
Crohn disease demonstrates gastric involvement
in approximately 33% of the cases. Granulomas
have also been described in association with
gastric malignancies, including carcinoma and
malignant lymphoma.
Sarcoidlike granulomas may be observed in
people who use cocaine, and foreign material is
occasionally observed in the granuloma.
Lymphocytic/ Eosinophilic
Gastritis
Lymphocytic gastritis
This is a type of chronic gastritis with dense infiltration of
the surface and foveolar epithelium by T lymphocytes and
associated chronic infiltrates in the lamina propria.
Eosinophilic gastritis
Large numbers of eosinophils may be observed with
parasitic infections such as those caused by Eustoma
rotundatum and anisakiasis.
Eosinophilic gastritis can be part of the spectrum of
eosinophilic gastroenteritis. Although the gastric antrum is
commonly affected, this condition can affect any segment
of the GI tract and can be segmental. Patients frequently
have peripheral blood eosinophilia..
Radiation/ Ischemic
Gastritis
Radiation gastritis
Small doses of radiation (up to 1500 R) cause reversible mucosal
damage, whereas higher radiation doses cause irreversible
damage with atrophy and ischemic-related ulceration. Reversible
changes consist of degenerative changes in epithelial cells and
nonspecific chronic inflammatory infiltrate in the lamina propria.
Higher amounts of radiation cause permanent mucosal damage,
with atrophy of fundic glands, mucosal erosions, and capillary
hemorrhage. Associated submucosal endarteritis results in
mucosal ischemia and secondary ulcer development.
Ischemic gastritis
Ischemic gastritis is believed to result from atherosclerotic
thrombi arising from the celiac and superior mesenteric arteries.
What are the symptoms?
Vomiting

Thirst

Nausea
Bloating

Indigestion

Pain in
Epigastric
Region
...symptoms

Gastrointestinal bleeding
Hemoptysis
Melena
Diarrhea
Chest Pain (associated with indigestion)
Unpleasant taste in mouth
Apetite
 How do we diagnose?
A doctor suspects gastritis when a person has
upper abdominal discomfort or pain or nausea.
Blood tests
Liver, Kidney, Gallbladder and Pancreas
functions
Urinalysis/stool sample
X-ray/ECG
Nasogastric Intubation
ENDOSCOPY
Capsule Endoscopy
Laparoscopy
Endoscopy

Endoscopy is an examination of internal structures using a flexible

viewing tube (endoscope).
 Endoscope is passed through the mouth, to
the stomach, examining the lining of the
stomach
Many endoscopes are equipped with a small
clipper with which tissue samples can be
taken (endoscopic biopsy)
Endoscopes can also be used for treatment.
 Capsule Endoscopy
Capsule endoscopy is a procedure in
which the person swallows a battery-
powered capsule.
The capsule contains one or two small
cameras, a light, and a transmitter.
Images of the lining of the intestines are
transmitted to a receiver worn on the
person's belt or in a cloth pouch.
Thousands of pictures are taken.
This technology is especially good at
finding problems on the inner surface of
the small intestine, which is an area that
is difficult to evaluate with an
endoscope.
Nasogastric Tube
Intubation of the digestive
tract is the process of
passing a small, flexible
plastic tube (nasogastric
tube) through the nose or
mouth into the stomach or
small intestine.
This procedure may be
used for diagnostic or
treatment purposes.
Nasogastric intubation can
be used to obtain a sample
of stomach fluid.
This determines whether
the stomach contains The tube is passed through the nose rather
blood, or they can analyze than through the mouth, primarily because
the stomach's secretions the tube can be more easily guided to the
for acidity, enzymes, and
other characteristics. oesophagus.
Also, passage of a tube through the nose is
less irritating and less likely to trigger
coughing.