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Toronto Notes 2019 Stomach and Duodenum Gastritis
Definition
• definedhistologically:inflammationofthestomachmucosa
Etiology
• somecausativeagentsmayplayaroleinmorethanonetypeofgastritisandanindividualpatientmay have histopathological evidence of more than one type of gastritis
Table 5. Updated Sydney Classification of Gastritis
Gastroenterology G11
Type
Acute Gastritis
Hemorrhagic/erosive gastritis Helicobacter gastritis
Chronic Gastritis
Non-atrophic
Atrophic
Chemical
Radiation
Lymphocytic
Eosinophilic
Non-infectious granulomatous Other infectious gastritides
Clinical Features
Common Etiology
Alcohol, Aspirin®/NSAID, shock/physiological stress (seen in ICU patients)
H. pylori*
H. pylori
H. pylori, dietary, environmental factors (multi-focal), autoimmunity NSAID, bile
Radiation injury
Celiac disease, drug
Food allergies
Crohn’s disease, sarcoidosis
Bacteria, viruses, fungi, parasite, TB, syphilis
• non-erosivegastritisisasymptomatic(exceptincertainrarecauseslikeCrohn’sdisease),doesnotcause pain; difficult to diagnose clinically or endoscopically – requires biopsy for diagnosis
• erosivegastritiscancausebleeding(painonlyifprogressestoulcers–rare);canbeseenendoscopically
Treatment
• determinedbyetiology(seeH.pylori,G13,NSAID,G13andStress-InducedUlceration,G14)
• non-pharmacological:avoidanceofmucosalirritantssuchasalcohol,NSAIDs,andfoodsthattrigger
symptoms
Peptic Ulcer Disease
Definition
• focaldefectsinthemucosathatpenetratethemuscularismucosallayer;resultsinscarring(defects superficial to the muscularis mucosa are erosions and do not cause scarring)
• pepticulcerdiseaseincludesdefectslocatedinthestomach(gastriculcers)andduodenum(duodenal ulcers)
Etiology
Table 6. Etiology of Peptic Ulcer Disease
Duodenal Gastric
H. pylori Infection 90% 60% NSAIDs 7% 35% Physiologic Stress-Induced <3% <5% Zollinger-Ellison Syndrome <1% <1% Idiopathic 15% 10%
• NSAIDnegative,H.pylorinegativeulcersbecomingmorecommonlyrecognized
• others: CMV, ischemic, idiopathic
• alcohol: damages gastric mucosa but rarely causes ulcers
• pepticulcerassociatedwithcigarettesmoking,cirrhosisofliver,COPD,andchronicrenalfailure
Clinical Features
• dyspepsia:mostcommonpresentingsymptom
■ only 5% of patients with dyspepsia have ulcers, while most have functional disease ■ however, 70% of peptic ulcers are asymptomatic
• maypresentwithcomplications
■ bleeding 10% (severe if from gastroduodenal artery), perforation 2% (usually anterior ulcers),
gastric outlet obstruction 2%
■ posterior inflammation (penetration) 2%; may also cause pancreatitis
Cigarette Smoking and PUD
• Increased risk of ulcer
• Increased risk of complications
• Increased chance of death from ulcer • Impairs healing