Basics
Description
Microscopic inflammation of mucosa of stomach
Epidemiology
- Most common cause of upper GI tract hemorrhage in older children
- 8 out of every 1,000 people are estimated to have gastritis.
- >2% of ICU patients have heavy bleeding secondary to gastritis.
Etiology
- Physiologic stress (e.g., chronic disease, CNS disease, overwhelming sepsis, ICU patients)
- Peptic disease
- Drug-induced (e.g., NSAIDs, steroids, valproate; more rarely, iron, calcium salts, potassium chloride, antibiotics)
- Infection (e.g., tuberculosis, Helicobacter pylori, cytomegalovirus, parasites)
- H. pylori (children more likely to have more severe gastritis, specifically located in antrum of stomach)
- Celiac disease: lymphocytic gastritis
- Major surgery; severe burns; renal, liver, respiratory failure; severe trauma
- Caustic ingestions (e.g., lye, strong acids, pine oil)
- Protein sensitivity (e.g., cow's milk-protein allergy), allergic enteropathy
- Eosinophilic gastroenteritis
- Crohn disease: Up to 40% of Crohn patients have gastroduodenal involvement.
- Gastric Crohn disease may manifest itself as highly focal, non-H. pylori, nongranulomatous gastritis.
- Direct trauma (nasogastric tubes)
- Ethanol
- Idiopathic
- Less common causes:
- Radiation
- Hypertrophic gastritis (M ©n ©trier disease)
- Autoimmune gastritis
- Collagenous gastritis
- Zollinger-Ellison syndrome
- Vascular injury
Diagnosis
History
- Epigastric pain
- Abdominal indigestion
- Nausea
- Vomiting postprandially
- Vomiting blood or coffee ground-like material
- Diarrhea
- Dark or black stools (or bright red blood from rectum, if bleeding is brisk and intestinal transit time is short)
- Irritability
- Poor feeding and weight loss
- Less often: chest pain, hematemesis, melena
Physical Exam
- Epigastric tenderness is physical finding that most closely correlates with gastritis on endoscopy.
- Normal bowel sounds
Diagnostic Tests & Interpretation
Lab
- CBC
- Evaluate for anemia with other signs of chronic blood loss (e.g., microcytosis, low reticulocyte count).
- Heme testing stool may be helpful.
- H. pylori identification
- Noninvasive H. pylori tests, including antibody (from serum, whole blood, saliva, or urine), antigen (from stool), or urea breath testing (UBT)
- UBT (using C13) and stool antigen tests are more reliable and sensitive than antibody testing; serologic testing is not recommended. However, UBT is not widely available and is used primarily in adults.
- Rapid urease test from gastric biopsy specimen for H. pylori
Imaging
- Upper GI radiography when endoscopy not available
- Chest radiograph may detect free abdominal air secondary to perforation.
Endoscopy
Upper endoscopy with biopsies
- Greatest sensitivity for gastritis
- Possible gross findings:
- Erythema, granularity, edema, small ulcerations
- Thickened hyperemic mucosa
- Atrophic mucosa
- Antral micronodules (represent lymphoid follicles) commonly seen in children with H. pylori infection
- Antral and prepyloric edema with retained gastric secretions
- Biopsies will show chronic and/or active inflammation.
- Can order special staining (Silver Warthin-Starry stain, Genta stain, modified Giemsa stain, or cresyl violet stain) of gastric biopsy for H. pylori
- Culture and sensitivities of homogenized gastric biopsy for H. pylori (difficult to perform outside of research setting)
Differential Diagnosis
- Gastroesophageal reflux with esophagitis
- Peptic ulcer disease
- Biliary tract disorders
- Pancreatitis
- Inflammatory bowel disease
- Genitourinary pathology (renal stones, infection)
- Nonulcer dyspepsia
- Functional pain
- Allergic enteropathy
Treatment
Medication
- Proton pump inhibitors: drug of choice as 1st-line therapy. Can also use antacids or H2 blockers to maintain gastric pH >4-5
- Ranitidine: 2-3 mg/kg/dose b.i.d.-t.i.d. in children
- Famotidine: 0.5-2 mg/kg/24 h divided b.i.d.
- Omeprazole, lansoprazole, rabeprazole, or esomeprazole: 1-2 mg/kg/24 h divided b.i.d.
- Interactions: Cimetidine is less effective and can increase toxicity when given to patients receiving other medicines metabolized by cytochrome P450 system (e.g., theophylline). Proton pump inhibitors can also interfere with the absorption of other medicines and may interact with other medicines metabolized by specific cytochrome P450 isoenzymes.
- Misoprostol
- Synthetic prostaglandin E1 (PGE1)
- May reduce risk of progression of gastritis to ulcers in patients taking NSAIDs
- Concerns exist for increased cardiovascular events in adults when using misoprostol.
- Discontinue NSAIDs.
- Treatment of H. pylori:
- Triple therapy with proton pump inhibitor and antibiotics (e.g., omeprazole, amoxicillin, and clarithromycin)
- If eradication unsuccessful, quadruple therapy is recommended for 7-14 days, including the following:
- Bismuth (of note, may need to avoid bismuth subsalicylate and choose instead bismuth subcitrate)
- Metronidazole
- A proton pump inhibitor
- Another antibiotic (either amoxicillin, clarithromycin, or tetracycline)
- Drug regimens change frequently; clarithromycin resistance becoming increasingly problematic
Alert
- Antacids are not palatable to children and can lead to diarrhea or constipation. Prolonged use of large doses of aluminum hydroxide-containing antacids may lead to phosphate depletion and aluminum-related CNS toxicity (particularly in patients with renal disease).
- If H. pylori eradication is attempted, important to use a tested regimen. Untested substitutions in the triple or quadruple regimens should be avoided.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- For stress gastritis with hemorrhage, provide vigilant supportive care with close monitoring of hemodynamics, fluids, and electrolytes.
- Monitor for Hemoccult-positive stools.
- Follow CBCs.
- May elect to repeat endoscopy in severe cases
Diet
- Benefit of changes in diet is inconclusive.
- Eliminate alcohol, tobacco, and caffeine, as well as NSAIDs.
Prognosis
- Significant gastritis relapse rates for children who remain infected with H. pylori
Complications
- Bleeding (from mild to hemorrhagic)
- When gastritis caused by acid/alkali ingestions, outlet obstruction may result from prepyloric strictures (4-8 weeks after ingestion).
Additional Reading
- Aanpreung P. Hematemesis in infants induced by cow milk allergy. Asian Pac J Allergy Immunol. 2003;21(4):211-216. [View Abstract]
- Drumm B, Koletzko S, Oderda G. Helicobacter pylori infection in children: a consensus statement. European Paediatric Task Force on Helicobacter pylori. J Pediatr Gastroenterol Nutr. 2000;30(2):207-213. [View Abstract]
- Hino B, Eliakim R, Levine A, et al. Comparison of invasive and non-invasive tests diagnosis and monitoring of Helicobacter pylori infection in children. J Pediatr Gastroenterol Nutr. 2004;39(5):519-523. [View Abstract]
- Pashankar DS, Bishop WP, Mitros FA. Chemical gastropathy: a distinct histopathologic entity in children. J Pediatr Gastroenterol Nutr. 2002;35(5):653-657. [View Abstract]
- Vesoulis Z, Lozanski G, Ravichandran P, et al. Collagenous gastritis: a case report, morphologic evaluation, and review. Mod Pathol. 2000;13(5):591-596. [View Abstract]
- Weinstein WM. Emerging gastritides. Curr Gastroenterol Rep. 2001;3(6):523-527. [View Abstract]
- Zheng PY, Jones NL. Recent advances in Helicobacter pylori infection in children: from the petri dish to the playground. Can J Gastroenterol. 2003;17(7):448-454. [View Abstract]
- Zimmermann AE, Walters JK, Katona BG, et al. A review of omeprazole use in the treatment of acid-related disorders in children. Clin Ther. 2001;23(5):660-679. [View Abstract]
Codes
ICD09
- 535.50 Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
- 535.51 Unspecified gastritis and gastroduodenitis, with hemorrhage
- 535.40 Other specified gastritis, without mention of hemorrhage
- 535.41 Other specified gastritis, with hemorrhage
ICD10
- K29.70 Gastritis, unspecified, without bleeding
- K29.71 Gastritis, unspecified, with bleeding
- K29.60 Other gastritis without bleeding
- K29.61 Other gastritis with bleeding
SNOMED
- 4556007 Gastritis (disorder)
- 276527006 Gastritis of newborn (disorder)
- 2367005 Acute hemorrhagic gastritis (disorder)
- 52305004 Gastritis medicamentosa (disorder)
FAQ
- Q: Will a bland diet help to resolve gastritis?
- A: Dietary changes have not been shown to affect the natural course of gastritis.
- Q: What is H. pylori?
- A: H. pylori is a bacterium frequently found in the gastric mucosa of patients with gastritis and peptic ulcer disease. It can be diagnosed by a variety of means, often including a combination of upper endoscopy and urea breath tests. Relapse rates for gastritis secondary to H. pylori are high when the infection is left untreated.
- Q: Is it appropriate to treat cases of gastritis with antibiotics not proven to be H. pylori?
- A: No. It is important to treat only confirmed H. pylori infections, not to treat on suspicion of infection, especially with increasing issues with antibiotic resistance.
- Q: If a patient is treated for H. pylori and they still have symptoms and a positive stool H. pylori Ag, what would be the next course of action?
- A: Consider retreating with a proton pump inhibitor, amoxicillin, and Flagyl, as clarithromycin resistance in H. pylori infection is an increasingly frequent cause for treatment failure.
- Q: What are newly recognized complications of treating patients with proton pump inhibitors?
- A: Some adult studies show hypomagnesemia, increased risk of pneumonia, hip fracture, and Clostridium difficile infection are associated with proton pump inhibitor use.