Gastritis

What gastritis is

The wall of the stomach is lined with a mucosa that produces mucus and protects the stomach from the acid it makes to digest food. When this protection is damaged, the lining becomes inflamed: this is gastritis. It can be acute (appearing suddenly and lasting briefly, for example after alcohol or a course of anti-inflammatory drugs) or chronic (developing slowly and lasting for years, usually from Helicobacter pylori).

The related term gastropathy is used when the lining is damaged with little or no inflammation, for example by medicines or alcohol. In everyday speech both are called “gastritis,” but the doctor distinguishes them because they have different causes and treatment.

It is important to know that pain, bloating or difficult digestion are not enough to say someone has gastritis. The same complaints are caused by functional dyspepsia (a stomach that works poorly without visible damage), peptic ulcer, gastroesophageal reflux, gallstones and, rarely, more serious disease. The exact diagnosis of gastritis is made with histologic examination of a biopsy taken during gastroscopy.

Symptoms

Many people with gastritis, especially the chronic form, have no complaints and learn of it by chance during a gastroscopy. When symptoms occur, they may be:

• pain or burning in the upper abdomen (epigastrium);
• nausea and, at times, vomiting;
• a feeling of early fullness while eating;
• heaviness, bloating or discomfort after meals.

These complaints vary from day to day and do not always reflect the degree of inflammation: some people have strong complaints and an almost normal lining, and others have visible inflammation with no discomfort at all.

Causes

• Helicobacter pylori infection, a bacterium that lives in the stomach, is the most important cause of chronic gastritis. Infection usually occurs in childhood and, without treatment, can persist for decades.
• Nonsteroidal anti-inflammatory drugs (ibuprofen, diclofenac, naproxen and similar) and aspirin, which block the production of substances that protect the lining.
• Alcohol and bile reflux (bile flowing back into the stomach, for example after stomach surgery).
• Autoimmune gastritis: the immune system attacks the stomach cells that produce acid and the factor needed to absorb vitamin B12. Over time it can lead to iron and vitamin B12 deficiency (anemia).
• Severe physical stress, in critically ill patients (for example in intensive care). This is a different mechanism from ordinary emotional stress, which may worsen complaints but does not itself cause gastritis.
• More rarely: other infections, inflammatory diseases such as Crohn disease, radiation.

In long-standing chronic gastritis, atrophy of the lining and, in some people, intestinal metaplasia may develop. These changes are seen only on biopsy and call for follow-up tailored by the doctor.

When to see a doctor

Book a visit if complaints last more than a few weeks, keep returning or do not improve with usual measures. Seek faster assessment, without waiting, if you have:

• unexplained weight loss;
• anemia or marked fatigue;
• difficulty or pain when swallowing;
• repeated vomiting or vomiting that will not stop;
• very early fullness, or a first onset of complaints at an older age;
• a family history of stomach cancer.

These are called “alarm features” and usually call for gastroscopy, because they show that the complaints may not be simple.

How the diagnosis is made

The doctor asks about symptoms, the medicines you take (especially anti-inflammatory drugs and aspirin), alcohol, smoking and family history. As appropriate, the following are recommended:

• Urea breath test or stool antigen test: detect active H. pylori infection. Before them the doctor may ask you to stop antibiotics for a few weeks and proton pump inhibitors for about two weeks, because these medicines can falsely make the test negative. Do not stop them without advice.
• Blood antibodies do not distinguish active infection from a past one, so they are not used to confirm infection or cure.
• Blood tests for anemia, iron and vitamin B12 when autoimmune gastritis is suspected.
• Gastroscopy with biopsy is recommended when there are alarm features, when complaints persist or do not respond to treatment, or when the lining needs to be seen directly. The biopsy distinguishes the type of gastritis and detects atrophy or metaplasia.

Not every stomach pain needs gastroscopy. The decision depends on age, alarm features and risk factors: in a young person without alarm features, one often starts with the H. pylori test and treatment.

How it is treated

Treatment targets the cause and the healing of the lining:

• H. pylori is treated with a combination of medicines (usually several antibiotics together with a proton pump inhibitor and, often, bismuth) for about two weeks. After treatment, at least four weeks later, a test of cure confirms eradication. Taking every dose correctly is decisive for success.
• Medicines that harm the stomach are reviewed with the doctor. Aspirin prescribed for the heart or brain is not stopped on your own: the doctor decides whether stomach protection or a change in treatment is needed.
• Proton pump inhibitors (PPIs), such as omeprazole, reduce acid production and help the lining heal. Antacids neutralize acid already in the stomach and give only temporary relief.
• In autoimmune gastritis, treatment of iron or B12 deficiency (often with injections or high-dose tablets) and periodic follow-up may be needed.

Do not take antibiotics on your own and do not stop prescribed medicines. The doctor also decides whether a check after treatment is needed.

Diet and daily care

There is no single diet that cures gastritis, and very strict diets are not needed. Helpful advice is simple:

• limit alcohol and stop smoking, which delay healing of the lining;
• avoid the foods that, in your own experience, worsen your complaints (often fried, spicy or very fatty foods), without cutting out many foods unnecessarily;
• eat regular meals in moderate amounts; do not lie down right after eating;
• do not take anti-inflammatory drugs unnecessarily; for pain, ask your doctor about alternatives.

With treatment of the cause, most gastritis heals or is well controlled. Contact the doctor if complaints return, or if any alarm feature appears.