Gastritis, Emergency Medicine

Basics

Description

Inflammatory response of gastric mucosa to injury-"gastritis"�
3 lines of defense of gastric mucosa:
- Mucous layer that forms protective pH gradient
- Surface epithelial cells that can repair small defects
- Postepithelial barrier that neutralizes any acid that has traversed 1st 2 layers
No definite link between histologic gastritis and dyspeptic symptoms
Epithelial cell damage with no associated inflammation-"gastropathy"�

Etiology

Common causes of gastritis: Infections, autoimmune, drugs (i.e., cocaine), hypersensitivity, stress
Common causes of gastropathy: Endogenous or exogenous irritants, such as bile reflux, alcohol, or aspirin and NSAIDs, ischemia, stress, chronic congestion
Acute gastritis:
- Stress (sepsis, burns, trauma):
  - Decrease in splanchnic blood flow leading to decreased mucus production, bicarbonate secretion, and prostaglandin synthesis
  - Results in mucosal erosions and hemorrhage
- Alcohol:
  - Induces production of leukotrienes that cause microvascular stasis, engorgement, and increased vascular permeability
  - Leads to hemorrhage
- NSAIDs, including aspirin:
  - Interfere with prostaglandin synthesis, leading to similar cascade as induced by alcohol
  - Results in mucosal erosions
- Steroids
Chronic gastritis:
- Produced by Helicobacter pylori
- Mechanism of H. pylori unclear:
  - Gram-negative spiral bacteria found in gastric mucous layer
  - Contains enzyme urease that allows it to change pH level (alkaline) of its microenvironment

Diagnosis

Signs and Symptoms

Dyspepsia
Bloating
Nausea/vomiting
Anorexia
Epigastric tenderness
Heartburn

History

Dyspepsia
Epigastric pain or discomfort (episodic and chronic)
Bloating, indigestion, eructation, flatulence, and heartburn
Anorexia, nausea/vomiting
Hematemesis, melena

Physical Exam

Careful physical exam including stool Hemoccult testing and vital signs with orthostatics
Dehydration, tachycardia (with vomiting)
Pallor (hemorrhagic gastritis)
Abdominal exam
Nonspecific
Epigastric tenderness

Essential Workup

ABCs
Hematocrit determination
Evaluation for dehydration/shock

Diagnosis Tests & Interpretation

Lab

Normal lab values in uncomplicated gastritis
CBC:
- Anemia with acute hemorrhagic gastritis
- Leukocytosis: Infection
Electrolytes, BUN, creatinine, glucose
Amylase/lipase for pancreatitis in differential
Urinalysis:
- Assess dehydration/ketosis (starvation)
- Bilirubin present with hepatitis

Diagnostic Procedures/Surgery

ECG:
- For elderly patients
- Myocardial ischemia in differential
Endoscopy:
- Outpatient unless significant hemorrhage
- Allows for visualization of bleeding sites, histologic confirmation of mucosal inflammation, and detection of H. pylori
Noninvasive H. pylori testing:
- 13C and 14C urea breath tests
- Stool antigen test
- Serology to detect antibodies to H. pylori
- Serum pepsinogen isoenzymes
  - The ratio of pepsinogen isozymes I and II in serum correlates with presence of metaplastic atrophic gastritis (principally autoimmune metaplastic atrophic gastritis and pernicious anemia)

Differential Diagnosis

Peptic ulcer disease (PUD)
Nonulcer dyspepsia (symptoms without ulcer on endoscopy)
Gastroesophageal reflux
Biliary colic
Cholecystitis
Pancreatitis
Hepatitis
Abdominal aortic aneurysm
Aortic dissection
Myocardial infarction

Treatment

Pre-Hospital

ABCs
IV fluid resuscitation

Initial Stabilization/Therapy

ABCs with acute erosive or hemorrhagic gastritis that presents with hemodynamic instability
IV fluid resuscitation with lactated Ringer solution or 0.9% normal saline (NS) via 2 large-bore catheters
NGT for gastric decompression and lavage when history of hematemesis or unstable vital signs
Foley catheterization to assess volume replacement

Ed Treatment/Procedures

Pain control with:
- Antacids
- GI cocktail:
  - 30 mL antacids + 10-20 mL viscous lidocaine
- H2 antagonists
- Proton pump inhibitors (PPIs)
- Sucralfate
- Avoid narcotics-may mask serious illness
Acute hemorrhagic gastritis:
- IV fluid resuscitation
- Blood transfusion if low hematocrit
- Reverse causes (alcohol, sepsis, NSAIDs, or trauma)
- Prevent acute or erosive gastritis in critically ill:
  - Antacids hourly or IV PPI or H2 antagonists
  - Goal is to keep pH level at >4
Chronic gastritis-H. pylori therapy:
- Treatment of H. pylori infection:
  - Invasive or noninvasive testing to confirm infection
  - Oral (PO) eradication antibiotic therapy options
- Most common therapies for H. pylori infection:
  - PPI (omeprazole 20 mg or lansoprazole 30 mg), clarithromycin 500 mg BID for 2 wk, amoxicillin 1 g BID for 2 wk.
  - For penicillin-allergic patients: PPI + clarithromycin 500 mg BID + metronidazole 500 mg BID for 14 days
  - 4-drug therapy: H2 blocker, bismuth subsalicylate (Pepto-Bismol) + either amoxicillin 1,000 mg BID or tetracycline 500 mg QID in combination with either metronidazole 250 mg QID or clarithromycin 500 mg BID for 14 days
- Drug resistance in US:
  - Metronidazole: 30-48%
  - Clarithromycin: >10%
  - Amoxicillin: Uncommon
  - Bismuth: None
- Treatment controversial for asymptomatic or nonulcer dyspepsia gastritis
Vitamin B12 supplementation for atrophic gastritis

Medication

Bismuth subsalicylate: 525 mg tabs 2 PO QID not to exceed 8 doses in 24 hr
Cimetidine (H2 blocker): 800 mg PO at bedtime nightly (peds: 20-40 mg/kg/24 h) for 6-8 wk
Famotidine (H2 blocker): 40 mg PO at bedtime nightly (peds: 0.5-0.6 mg/kg q12h) for 6-8 wk
Lansoprazole (PPI): 30 mg PO BID for 2 wk
Maalox Plus: 2-4 tablets PO QID
Misoprostol: 100-200 μg PO QID
Mylanta II: 2-4 tablets PO QID
Nizatidine (H2 blocker): 300 mg PO at bedtime nightly for 6-8 wk
Omeprazole (PPI): 20 mg PO BID (peds: 0.6-0.7 mg/kg q12-24 h) for 2 wk
Pantoprazole (PPI): 40 mg PO/IV daily for 2 wk
Ranitidine (H2 blocker): 300 mg PO at bedtime nightly (peds: 5-10 mg/kg/24 h given q12h) for 6-8 wk
Sucralfate: 1 g PO QID for 6-8 wk

First Line

Triple therapy using a PPI with clarithromycin and amoxicillin or metronidazole given twice daily remains the recommended 1st choice treatment.
Sequential 10-day therapy in high prevalence areas:
- Double therapy for 5 days:
  - PPI
  - Amoxicillin
- Followed by triple therapy for 5 days:
  - PPI
  - Clarithromycin
  - Metronidazole

Second Line

Bismuth-based quadruple therapies remain the best 2nd choice treatment.
The rescue treatment should be based on antimicrobial susceptibility testing.

Follow-Up

Disposition

Admission Criteria

Acute hemorrhagic or erosive gastritis that presents with upper GI tract bleeding, tachycardia, and hypotension
Uncontrolled pain or vomiting
Coagulopathy from medication or liver disease

Discharge Criteria

Unremarkable physical exam with normal CBC and heme-negative stools
If heme-positive stools, discharge if stable vital signs, normal hematocrit, and negative NGT aspiration for upper GI tract hemorrhage:
- Outpatient evaluation for endoscopy

Issues for Referral

Outpatient referral for endoscopy and H. pylori testing
Biopsy for gastric dysplasia and malignancy

Followup Recommendations

Close follow-up with gastroenterologist for endoscopy with biopsy for diagnostic reasons. �

Pearls and Pitfalls

Gastritis/gastropathy is a common presentation to ED.
Symptoms typically are dyspepsia, nausea, and vomiting.
ED management depends on patients clinical symptoms, but should include diagnostic and therapeutic components.
Therapeutic management usually involves treatment of H. pylori.
Drug resistance of H. pylori to antibiotics is increasing.
Close follow-up with gastroenterologist recommended for biopsy and to detect gastric cancers.

Additional Reading

Czinn �SJ. Helicobacter pylori infection: Detection, investigation, and management. J Pediatr. 2005;146:S21-S26.
Eswaran �S, Roy �MA. Medical management of acid-peptic disorders of the stomach. Surg Clin North Am. 2005;85:895-906.
Haj-Sheykholeslami �A, Rakhshani �N, Amirzargar �A, et al. Serum pepsinogen I, pepsinogen II, and gastrin 17 in relatives of gastric cancer patients: Comparative study with type and severity of gastritis. Clin Gastroenterol Hepatol. 2008;6:174-179.
Malfertheiner �P, Megraud �F, O'Morain �C, et al. Current concepts in the management of Helicobacter pylori infection: The Maastricht III Consensus Report. Gut. 2007;56(6):772-781.
Oishi �Y, Kiyohara �Y, Kubo �M, et al. The serum pepsinogen test as a predictor of gastric cancer: The Hisayama study. Am J Epidemiol. 2006;163:629-637.
Ricci �C, Vakil �N, Rugge �M, et al. Serological markers for gastric atrophy in asymptomatic patients infected with Helicobacter pylori. Am J Gastroenterol. 2004;99:1910-1915.
Wu �W, Yang �Y, Sun �G. Recent insights into antibiotic resistance in Helicobacter pylori eradication. Gastroenterol Res Pract. 2012:8. doi:10.1155/2012/723183.

Codes

ICD9

535.00 Acute gastritis, without mention of hemorrhage
535.30 Alcoholic gastritis, without mention of hemorrhage
535.50 Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
535.10 Atrophic gastritis, without mention of hemorrhage
535.01 Acute gastritis, with hemorrhage
535.0 Acute gastritis
535.11 Atrophic gastritis, with hemorrhage
535.1 Atrophic gastritis
535.31 Alcoholic gastritis, with hemorrhage
535.3 Alcoholic gastritis
535.51 Unspecified gastritis and gastroduodenitis, with hemorrhage
535.5 Unspecified gastritis and gastroduodenitis

ICD10

K29.00 Acute gastritis without bleeding
K29.20 Alcoholic gastritis without bleeding
K29.70 Gastritis, unspecified, without bleeding
K29.50 Unspecified chronic gastritis without bleeding
K29.01 Acute gastritis with bleeding
K29.0 Acute gastritis
K29.21 Alcoholic gastritis with bleeding
K29.2 Alcoholic gastritis
K29.51 Unspecified chronic gastritis with bleeding
K29.5 Unspecified chronic gastritis
K29.71 Gastritis, unspecified, with bleeding
K29.7 Gastritis, unspecified

SNOMED

4556007 Gastritis (disorder)
25458004 Acute gastritis (disorder)
2043009 Alcoholic gastritis (disorder)
8493009 chronic gastritis (disorder)
2367005 Acute hemorrhagic gastritis (disorder)
52305004 Gastritis medicamentosa (disorder)

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