15-22: Gastritis & Gastropathy

The term “gastropathy” should be used to denote conditions in which there is epithelial or endothelial damage without inflammation, and “gastritis” should be used to denote conditions in which there is histologic evidence of inflammation. In clinical practice, the term “gastritis” is commonly applied to three categories: (1) erosive and hemorrhagic “gastritis” (gastropathy); (2) nonerosive, nonspecific (histologic) gastritis; and (3) specific types of gastritis, characterized by distinctive histologic and endoscopic features diagnostic of specific disorders.

1. EROSIVE & HEMORRHAGIC “GASTRITIS” (GASTROPATHY)

General Considerations

The most common causes of erosive gastropathy are medications (especially NSAIDs), alcohol, stress due to severe medical or surgical illness, and portal hypertension (“portal gastropathy”). Major risk factors for stress gastritis include mechanical ventilation, coagulopathy, trauma, burns, shock, sepsis, CNS injury, liver failure, kidney disease, and multiorgan failure. The use of enteral nutrition reduces the risk of stress-related bleeding. Uncommon causes of erosive gastropathy include ischemia, caustic ingestion, and radiation. Erosive and hemorrhagic gastropathy typically are diagnosed at endoscopy, often being performed because of dyspepsia or upper GI bleeding. Endoscopic findings include subepithelial hemorrhages, petechiae, and erosions. These lesions are superficial, vary in size and number, and may be focal or diffuse. There usually is no significant inflammation on histologic examination.

Clinical Findings

A. Symptoms and Signs

Erosive gastropathy is usually asymptomatic. Symptoms, when they occur, include anorexia, epigastric pain, nausea, and vomiting. There is poor correlation between symptoms and the number or severity of endoscopic abnormalities. The most common clinical manifestation of erosive gastritis is upper GI bleeding, which presents as hematemesis, “coffee grounds” emesis, or bloody aspirate in a patient receiving nasogastric suction, or as melena. Because erosive gastritis is superficial, hemodynamically significant bleeding is rare.

B. Laboratory Findings

The laboratory findings are nonspecific. The hematocrit is low if significant bleeding has occurred; iron deficiency may be found.

C. Special Examinations

Upper endoscopy is the most sensitive method of diagnosis. Although bleeding from gastritis is usually insignificant, it cannot be distinguished on clinical grounds from more serious lesions such as peptic ulcers or esophageal varices. Hence, endoscopy is generally performed within 24 hours in patients with upper GI bleeding to identify the source. An upper GI series is sometimes obtained in lieu of endoscopy in patients with hemodynamically insignificant upper GI bleeds to exclude serious (eg, mass) lesions but is insensitive for the detection of gastritis.

Differential Diagnosis

Epigastric pain may be due to peptic ulcer, gastroesophageal reflux, gastric cancer, biliary tract disease, food poisoning, viral gastroenteritis, and ...