What is erosive gastritis?
Gastritis is a well known and common condition where the stomach wall is inflamed. It can be broadly classified as erosive or non-erosive. The term ‘erosive gastritis’ refers to a condition where there is minimal inflammation of the stomach wall but instead the wall wears away. This is seen as open sores (ulcers) or erosions. It is often considered to be a more serious type of gastritis because there is a potential for significant bleeding from the eroded or ulcerated site. Erosive gastritis can be both acute or chronic.
Erosive Gastritis and the Stomach Wall
The disease process in erosive gastritis is not significantly different from non-erosive gastritis. Firstly it is important to understand how the stomach is able to withstand the many insults it faces in a day, especially from the highly acidic stomach juices. Gastric acid and stomach enzymes like pepsin can quickly erode the stomach wall. To prevent this, the stomach has a layer of mucus that protects its walls from making contact with the stomach juices. Mucus-producing cells are working constantly to keep this mucus barrier intact.
Stomach Mucus and Prostaglandins
Various substances and microbes can compromise this mucus barrier. These agents cause inflammation of the stomach wall but also allow the stomach acid to make contact with the wall due to the compromised mucus barrier. It usually does not happen throughout the entire stomach wall but is isolated to a few patchy areas or even a single spot.The offending agents only play a smaller, albeit significant, role in the inflammation. It is more the way in which it reduces prostaglandin secretion, a substance that protects the stomach wall from the acid, that is the major component of the injury and inflammation in gastritis. By reducing prostaglandin secretion, more stomach acid is produced and less stomach mucus.
Stomach Erosion and NSAIDS
Although there are many factors that cause erosive gastritis, NSAIDs are by far the most common. NSAIDs (non-steroidal anti-inflammatory drugs) reduce inflammation by inhibiting prostaglandins – the chemical messenger for the inflammatory process in the body. In this way NSAIDs are very effective and relieving inflammation in the body. However, these effects are detrimental to the health of the stomach. By reducing prostaglandins at the site, more stomach acid is produced and less mucus. This allows the stomach to be severely damaged particularly where the NSAIDs have made contact with the wall. Since NSAIDs sink in the stomach when consumed, it explains why most of the erosion occurs on the greater curvature of the stomach.
Erosive Gastritis Causes
The two most common causes of gastritis are NSAIDs and Helicobacter pylori (H.pylori) infection. However, NSAIDs are a more common cause of erosive gastritis while H.pylori infection is responsible for non-erosive gastritis.
The mechanism by which NSAIDs causes erosive gastritis has been explained above. It is a result of prostaglandin inhibition. Although short term use of excessive quantities of NSAIDs can cause erosive gastritis, it is usually a consequence of long term NSAIDs use. Therefore NSAIDS are the most common cause of both acute and chronic erosive gastritis.
Alcohol and cocaine use are two other offending agents that may also contribute to erosive gastritis. It is usually in the long term setting of substance use, and misuse, that erosive gastritis arises due to alcohol and cocaine. Chronic alcoholism is among the leading causes of chronic erosive gastritis second to NSAIDs.
There is a common misconception that stress, or more specifically psychological stress, causes a type of gastritis known as stress gastritis. However, stress gastritis is caused by severe illness like burns, critical illnesses, extensive trauma and major surgery. While psychological stress can be an exacerbating factor, it is not usually a case of gastritis. Stress gastritis may be erosive in nature.
Injury to the stomach wall with radiation exposure and subsequent damage of the tissue is another cause of erosive gastritis. This is more frequently seen in cancer patient undergoing radiation therapy, particularly where the malignancy is in or near the stomach.
The following less common causes may be responsible for erosive and non-erosive gastritis.
- infections other than H.pylori
- autoimmune diseases, including autoimmune gastritis
- other diseases of the stomach and gut, including Crohns disease
Erosive Gastritis Symptoms
Most of the symptoms erosive gastritis are not significantly different from non-erosive gastritis.
- dull gnawing ache to burning pain in the upper abdomen
- change in pain and discomfort with eating, may be worse or better
- sometimes mild tenderness over the stomach area
- nausea, and sometimes vomiting
- changes in appetite
Erosive gastritis has more definitive symptoms when the ulcers and erosions being to bleed. This includes :
- black tarry stools (melena)
- blood in the vomit (hematemesis)
Erosive Gastritis Diagnosis
Although the signs and symptoms and the patient’s medical history may point to gastritis, further investigations are required to confirm the diagnosis of erosive gastritis. Blood and stool tests may confirm anemia with blood loss, infection and the presence of blood in the stool. However, imaging studies such as an upper gastrointestinal (GI) endoscopy or gastroscopy will confirm the diagnosis of erosive gastritis. The ulcers and erosions will be visible and other changes in the stomach such as enlargement of the stomach folds and nodules. Other investigations may include a double-contrast barium radiography where the patient ingests a radiocontrast dye and the stomach is highlighted on an x-ray.
Erosive Gastritis Treatment
The main approach to treatment is to first identify the cause and attend to it where possible. In terms of erosive gastritis, NSAIDs should be changed or discontinued altogether as well as other substances which may be a contributing factors. The medical treatment for erosive gastritis is similar to non-erosive gastritis.
- Antacids help to neutralize the stomach acid, ease symptoms such as pain and aid with healing.
- Acid-suppressing drugs such as proton pump inhibitors (PPIs) and H2-blockers decrease acid production and also aid with healing.
Other medication for treating gastritis like antibiotics is only necessary for H.pylori eradication therapy. Since H.pylori infection is unlikely to cause erosive gastritis, it is not usually necessary.