Gastritis

Teacher ： Dongxu Wang

Department of Gastroenterology

Shengjing Hospital
Review knowledge
Location of stomach:
Stomach is located centre left in the
human body ， between the
esophagus and the small intestine

Function of stomach:
Accept and store food,
Secretes digestive enzymes and
gastric acid to aid in food
digestion ，
Transportation and emptying
functions.
What is Gastritis ？
Gastritis refers to the inflammation of gastric
mucosa ， regardless of the cause.
Classification of Gastritis
Acute Gastritis
Chronic Gastritis
Special types of gastritis
Acute Gastritis
Acute Gastritis includes ：
1. Acute Helicobacter pylori （ H. pylori ） infection
gastritis

2. Pathogens other than H. pylori

Bacteria other than H. pylori （ Such as
Mycobacterium
tuberculosis 、 Staphylococcus aureus 、 Escherichia
coli 、
Streptococcus haemolyticus A 、 Syphilis 、 etc ）
Virus （ Such as Cytomegalovirus ）
Fungus
 Cause of Acute erosive - hemorrhagic gastritis

1 、 Drug
NSAIDs （ Non-steroidal anti-inflammatory drugs ）：
Such as Aspirin 、 Indometacin

Chemotherapeutic drugs
Cytotoxic effect of gastric mucosa

Oral Potassium chloride and Iron supplements

Cause gastric mucosa erosion
Why NSAIDs can cause acute gastritis ？

a. It can directly damage mucosal epithelium

b. NSAIDs is nonspecific cyclooxygenase(COX) inhibitors.
(Structural Type) COX1:Stable expression in tissues, promote the
COX production of prostaglandin E ,repair epithelial cells. 【 Protective 】
(Induced Type)COX2: Expression induced by inflammation, promoting
the production of inflammatory mediators. 【 Injurious 】

NSAIDs aims to inhibit COX-2 and reduce inflammatory response,

but at the same time, it can inhibit COX-1, so reduce prostaglandin E production
and cause mucosal damage, which are mostly seen in gastric antrum.
Cause of Acute erosive - hemorrhagic gastritis

2、 Stress state

Multiple
Severe surgery extensive Cerebrovasc
Septicemia organ
trauma operation burn ular disease
failure

In stress state: gastric mucosa microcirculation disorder, mucus decrease

and prostaglandin synthesis are insufficient, gastric acid secretion is
increased
Result: damage mucosa, cause erosion, bleeding and even ulcer
Cause of Acute erosive - hemorrhagic gastritis

3、 Alcohol
Alcohol is lipophilic and liposoluble,
which can cause gastric mucosal
erosion and bleeding

4 、 Physical factors
such as high dose radiation
 Clinical manifestation of Acute erosive -
hemorrhagic gastritis

Mild : dyspepsia 、 abdominal

pain 、 anorexia 、 nausea 、 vomiting.
Typical : Bleeding (hematemesis and melena)
Diagnosis ： Emergency gastroscopy within 24-48 hours
gastric mucosa appears
diffuse
erosion 、 hemorrhage
、
superficial ulceration .
 Treatment of Acute erosive - hemorrhagic
gastritis
1 、 Wipe out predisposing causes

2 、 Drugs ：
（ 1 ） Acid-inhibitory drugs
Proton pump inhibitor （ PPI ）
H2 receptor antagonist
（ 2 ） Mucosal protectant ：
Antacids （ Aluminium
Phosphate Gel 、 Hydrotalcite Tablets ）
（ 3 ） Antibiotics ： When bacterial infection exists
 Prognosis of Acute erosive - hemorrhagic
gastritis
Most acute gastric mucosal erosion and hemorrhage
can heal by themselves.

A few patients can develop into gastric ulcer, it needs

systematic drug treatment and has good response to drug
treatment
 Prevention of Acute erosive - hemorrhagic
gastritis
 Stop using unnecessary NSAIDs.
 PPI or H2RA can be given in case of severe stress
state or long-term oral administration of NSAIDs such as
aspirin
 Use selective COX 2 instead of non selective Cox, such
as celecoxib in patients with osteoarthritis
 Avoid alcohol and drug abuse
Chronic Gastritis
 Classification of Chronic Gastritis
Gastric antral gastritis

Non-atrophic Gastric body gastritis

gastritis

Chronic Total gastritis

Gastritis
Type A ： Autoimmune gastritis
 Mainly in gastric body
Atrophic  Mainly caused by autoimmune
gastritis
Type B ： Multifocal atrophic
gastritis
 Mainly in gastric antrum
 Mainly caused by H.pylori
 Cause of Chronic Gastritis
1. H.pylori ： the most important cause ！！！
H. pylori is a gram-negative bacterium
Spiral shape
Micro aerobic.

Chronic gastritis ； Peptic ulcer ；

Gastric mucosal-associated lymphoid tissue
(MALT) lymphoma ；
Gastric adenocarcinoma.
Epidemiology of H.pylori
 80% of the population may be infected by the age of 20.
 The prevalence of H. pylori varies throughout the world and
depends to a great extent on the overall standard of living in the
region.
 Route of transmission ： Oral - Oral （ saliva ） ； Fecal - Oral
 Risk Factors ： Low socioeconomic status , less education.
Domestic crowding
Unsanitary living conditions
Unclean food or water
Exposure to gastric contents of infected
individual
How H. pylori causes gastritis ？

 Release urease ， then decompose urea ， produce

NH3 ， maintain
the neutral environment around bacteria ， and facilitate the
colonization of H.pylori on the surface of gastric mucosa
 Secrete vacuolating cytotoxin A （ Vac A ）， cause cell damage
 Cytotoxin-associated gene A （ cag A ） proteins induce intense
inflammatory response
 Immune response induced by H.pylori cell wall as antigen
 Cause of Chronic Gastritis
2. Autoimmune factors ：
 Autoantibody in the blood
parietal cell antibody(PCA); intrinsic factor antibody(IFA)
 Often accompanied by other autoimmune diseases, such as
vitiligo ，
Hashimoto thyroiditis
 It can lead to the decrease of parietal cells, atrophy of glands,
decrease of gastric acid secretion and malabsorption of vitamin B12
 Cause of Chronic Gastritis
3. Dietary factors ：
High salt and lack of fresh fruits and vegetables

4. Other factors ：
Bile reflux ， Duodenal fluid reflux ， alcohol ， Drugs,
Old age . etc
 Gastroscopy of Chronic Gastritis
 In non-atrophic gastritis
we can see erythema of mucosa 、 rough and uneven
mucosa 、
bleeding spots 、 edema and exudation of mucosa under
gastroscopy
non- atrophic gastritis Normal
 Gastroscopy of Chronic Gastritis
 In atrophic gastritis ， there are two types.
a. Simple atrophic gastritis ： Mucosa red and white, mainly
white, blood vessels exposed, folds flat or even disappeared
b. Atrophic gastritis with hyperplasia ： The mucosa is
granular or nodular
atrophic gastritis Normal
 Pathology of Chronic Gastritis
Biopsy site of chronic gastritis: At least 5 biopsies
A1-A2: Lesser and greater curvature of antrum, mucinous gland
IA: Small curvature of gastric angle,common sites of early atrophy and
intestinal metaplasia
B1-B2: Anterior and posterior walls of stomach, acid secreting glands
Pathology of Chronic Gastritis

Inflammatory

Atrophy

Metaplasia

Dysplasia \ Intraepithelial neoplasia

 Pathology of Chronic Gastritis

 Inflammatory
Chronic gastritis is identified histologically by an inflammatory
cell infiltrate consisting primarily of lymphocytes and plasma cells,
with very scant neutrophil involvement.
 Pathology of Chronic Gastritis

 Atrophy
Destruction of glands, reduction of number of glands, fibrosis of
lamina propria.
 Pathology of Chronic Gastritis

 Metaplasia
Intstinal Metaplasia: Intestinal glands characterized by goblet
cells replace gastric glands.
Pseudopyloric Metaplasia: Hyperplasia of cervical mucus cells in
acid secreting glands,forming pyloroid glands
 Pathology of Chronic Gastritis

 Dysplasia \ Intraepithelial neoplasia

In the process of cell regeneration, there are overgrowth and lack
of differentiation, epithelial cells are crowded and has stratified
phenomenon, nuclear enlargement and loss of polarity, increased
mitotic image, and disorder of glandular structure
 Pathology of Chronic Gastritis

 Premalignent conditions:
atrophy, intestinal metaplasia, dysplasia

 Precancerous disease:
Atrophic gastritis with or without intestinal metaplasia,
gastric polyps, gastric ulcer and residual gastritis,
Ménétrier's disease
 Clinical manifestation of Chronic Gastritis
Symptoms ： Upper abdominal pain 、 Upper abdominal
discomfort 、 Uupper abdominal distension 、
Early satiety 、 Belching 、 Nausea 、
Dyspepsia

Special manifestations of autoimmune gastritis ：

Intrinsic factor antibodies bind to intrinsic factor
blocking the absorption of vitamin B12
Lack of vitamin B12 anemia
Examination of Chronic Gastritis
1. Gastroscopy and biopsy (major diagnostic evidence)

As mentioned earlier, refer to the previous slides

Examination of Chronic Gastritis
2 、 Detection of H. pylori
 Invasive examination ：
rapid urease test, histological examination, H. pylori culture

 Non-invasive examination
13 C-urea breath test ( 13-UBT)/ 14 C-urea breath test
Serum anti-Helicobacter pylori antibody （ IgG ）
antigen of Helicobacter pylori in stool
 Examination of Chronic Gastritis
2 、 Detection of H. pylori

13 C-urea breath test

14 C-urea breath test
Method

1. Exhaled gas for collection

before takeing the reagent

2. Take the reagent containing

carbon 13 ， and exhale
again after half an hour to
collect the gas

3. Detect carbon 13 labeled

carbon dioxide.
Principle of 13 C-urea breath
test ：
Helicobacter pylori contains
urease.

When it encounters the carbon

13/14 urea reagent taken in the
stomach, it will decompose it into
ammonia and carbon dioxide
containing carbon 13/14, and the
gas will be discharged with
respiration.

Collecting carbon 13/14 labeled

carbon dioxide in exhaled gas can
accurately prove whether there is
Helicobacter pylori infection.
Examination of Chronic Gastritis
3 、 Examination in autoimmune gastritis
parietal cell antibody(PCA)
intrinsic factor antibody(IFA)

4 、 Determination of serum gastrin 17 ， pepsinogen I and II

gastric body atrophic gastritis: gastrin 17 elevated, pepsinogen I
decrease , ratio of pepsinogen I to pepsinogen II decrease
gastric antrum atrophic gastritis : gastrin 17 decrease ,
pepsinogen
I normal 、 ratio of pepsinogen I to pepsinogen II normal
Total atrophic gastritis ： gastrin 17 and pepsinogen I all decrease
 Treatment of Chronic Gastritis
1. Remove pathogenic factors: quit smoking and alcohol,
chew carefully and swallow slowly, avoid overeating and
irritating food
2. anti-helicobacter pylori treatment
Quadruple therapy for eradication of Helicobacter pylori:
[ A kind of PPI + Two kind of antibiotics + Bismuth)
A kind of PPI (omeprazole, rabeprazole, pantoprazole,
lansoprazole or esomeprazole)
Two kind of antibiotics (Amoxicillin, Clarithromycin,
Levofloxacin or Metronidazole)
Bismuth(Bismuth potassium citrate ; Bismuth pectin)
 Treatment of Chronic Gastritis
3. Other drugs :
Mucosal protectant
Gastric motility drugs
traditional Chinese medicine

4. Treatment of dysplasia
Mild dysplasia should be followed up closely, besides medication,
recheck gastroscopy after 3-6 months.
Severe dysplasia requires preventive operation.( endoscopic
mucosal resection, or endoscopic submucosal dissection,or surgery)
Special types of gastritis
1. Infectious gastritis
Bacteria other than H. pylori ， Virus （ Such as
Cytomegalovirus ） and Fungus.
acute purulent gastritis ：
the disease was common pathogens of hemolytic
streptococcus A, Staphylococcus aureus and Escherichia coli.

Purulent inflammation often originated from submucosa,

and extended to the whole layer of the stomach.
The condition is dangerous.
Medical treatment is often ineffective and requires surgery.
2. Acute corrosive gastritis

Because of taking strong acid (such as sulfuric acid,

hydrochloric acid, nitric acid) or strong base (such as
sodium hydroxide, potassium hydroxide) or other
corrosives by oneself or by mistake.

Early clinical manifestations include severe pain in the

back of sternum and upper abdomen, bleeding or
perforation in severe cases, and scar stricture in the
esophagus and stomach in late stage.
3. Ménétrier's disease
（ Diffused or Giant Hypertrophic Gastritis ）
The stomach body and fundus plica are thick and
hypertrophic, and twisted like gyrus.
Histopathology of gastric mucosa showed prolongation and
distortion of gastric fovea, cystic dilatation in the depth,
decrease of parietal cells and main cells, and obvious thickening
of gastric mucosa.
The secretion of gastric acid decreased.
Hypoproteinemia (caused by loss of protein from gastric
juice)
The average age of onset is 40 to 60 years, and men are
affected more often than women.
Risk of gastric adenocarcinoma is increased in adults with
Ménétrier disease.
4. Others
Eosinophilic gastritis （ caused by exogenous or
endogenous allergy ）
lymphocytic gastritis （ related to celiac disease and
Helicobacter pylori ）
non-infectious granulomatous gastritis (such as gastric
Crohn' disease ， sarcoidosis)
radioactive gastritis (caused by radiotherapy)
congestive gastropathy (such as portal hypertensive
gastropathy)
Thank you for your attention