Gastritis

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Description

Gastritis can present as either acute or chronic gastritis. Helicobacter pylori is the commonest (80%) cause of gastritis.

In acute gastritis, there is inflammation of the superficial gastric mucosa. It can occur because of ingestion of drugs such as acetyl salicylic acid (ASA) and other non-steroidal anti-inflammatory drugs (NSAID) and alcohol.

Chronic gastritis is divided into 3 categories:

  • Type A (autoimmune) gastritis seen in pernicious anaemia and also in other autoimmune
  • Type B (bacterial) gastritis, which is associated with Helicobacter
  • Type C (chemical) gastritis, which is due to repeated injury with bile reflux or chronic ingestion of

NSAIDs.

Chronic gastritis

Signs and Symptoms

  • Indigestion
  • Vomiting
  • Haematemesis/melena (GI haemorrhage)
  • Epigastric pain

Most chronic gastritis is asymptomatic.

Investigations

Non-invasive

  • 13C-urea breath test
  • Fecal antigen test

Invasive (antral biopsy)

  • Rapid urease Test
  • Microbiological culture
  • Endoscopy
  • Histology

Treatment

(See notes under Chronic Peptic Ulcer Disease)

Remove offending cause

Triple therapy regimens: (1-week regimen)

  • Amoxicillin 1g 2 times daily

        Plus

  • Metronidazole 400mg 3 times daily

        Plus

  • Omeprazole 20mg twice daily or 40mg once daily for 7 days OR

Eradication Therapy (at higher levels of care)

  1. Clarithromycin Triple Therapy

        PPI + Clarithromycin + Metronidazole (7-14 Days)

  1. Bismuth Quadruple Therapy

        PPI + Tetracycline + Metronidazole + Bismuth (10-14              Days)

  1. Concomitant Therapy

        PPI + Clarithromycin + Amoxicillin + Tinidazole (3-10 Days)

  1. Sequential Therapy

        PPI + Amoxicillin (5 Days), Followed By

        PPI + Clarithromycin And Tinidazole For 5 Days

  1. Hybrid Therapy

        A cross between sequential and concomitant therapies              PPI + Amoxicillin for 7 days, followed by PPI +                        Clarithromycin +Tinidazole (or Metronidazole) for                    another 7 days

  1. Levofloxacin-Based Therapies

Levofloxacin based therapies have shown favorable results, and are highly favored, though in Zambia Levofloxacin remain protected for use in DR-TB treatment.

NB: When patient presents with persistent or non-improvement of symptoms refer to higher level for further management (which may include scoping)

Complications

Recurrent pylori infection

  • Barrett’s oesophagus
  • Frank haemorrhage and anaemia
  • Recurrent aspiration pneumonia
  • Perforation of peptic ulcer
  • Pyloric stenosis

Chronic Peptic Ulcer Disease

Description

Most peptic ulcers occur in the stomach or proximal duodenum but can also occur in the oesophagus (with oesophageal reflux).

Signs and Symptoms

  • Epigastric pain
  • Indigestion
  • Flatulence
  • Heartburn
  • Anorexia: weight loss may occur

Investigations

  • Endoscopy
  • Barium meal

NB: Many patients, particularly the young presenting with indigestion, can be treated symptomatically for 4-5 weeks without investigation.

Treatment

Refer to section on Gastritis where available or as below

Anti-acids

  • Magnesium trisilicate compound chewable tablet 250 - 500mg to chew when required or
  • Aluminium hydroxide chewable tablet 500mg - 1g to chew when required

        OR

  • Magnesium trisilicate suspension 250mg with dried Aluminium (indicate strength /per ml)hydroxide 120mg 10ml orally 3 times daily OR
  • Aluminium hydroxide (dried Aluminium hydroxide 500mg) 5 - 10ml orally 4 times daily; Children 6 - 12 years 5ml orally 3 times daily.
  • Adults 1 - 4 tablets to be chewed 4 times daily between meals and at bedtime or as required.

Anti-Secretory Agent

  1. H2–receptor antagonists

Cimetidine 400mg tablets twice daily (with breakfast and at night) or 800mg at night for at least 4 weeks.

Maintenance 400mg at night or 400mg morning and night.

Reflux oesophagitis:

  • Cimetidine 400mg 4 times daily for 4 – 8

        OR

  • Ranitidine 150mg tablets twice daily (with breakfast and at night) or 300mg at night for 4 – 8 weeks, up to 6 weeks in chronic episodic dyspepsia. Maintenance 150mg at night.
  • Ranitidine 150mg twice daily or 300mg at night for up to 8 weeks or if necessary 12

        OR

  • Famotidine 20-40mg once daily up to 8 weeks

b. Proton pump inhibitors

  • Omeprazole 20mg tablets daily for 4 weeks followed by a further 4 – 8 weeks if not fully
  • Long term management of acid reflux Omeprazole 10mg daily increasing up to 20mg if symptoms return. Not recommended for children under 3kg
  • Children under 3kg - 5kg 0.7 to 1.4mg/kg daily
  • Child 5 to 10kg: 5mg once daily in morning, child 10kg to 20kg: 10mg once daily in morning

        OR

  • Esomeprazole 20-40mg once daily for 4-8 weeks

        OR

  • Rabeprazole 20mg twice daily for 4-8 weeks

c. Tripotassium dicitrabismuthate (Bismuth chelate)

  • Liquid 12mg/5ml. 10ml twice daily or 5ml 4 times daily for 28 days followed by a further 28 days if necessary. Not recommended for children.
  • Tablets 120mg. 2 tablets twice daily or 1 tablet 4 times daily for 28 days followed by a further 28 days if necessary.

d. Triple therapy regimens

14-day regimen

  • Amoxycillin 1g 2 times daily Plus
  • Metronidazole 400mg 2 times daily Plus
  • Omeprazole 20mg twice daily or 40mg once daily for 14 days

        OR

 Alternative: Clarithromycin 500mg daily twice daily Plus Metronidazole 400mg (or Tinidazole 500mg) twice daily for 7 days Plus Omeprazole 20mg twice daily for 14 days.

Complications

  • Change of the oesophageal mucosa (Barrett’s oesophagus) which is
  • Anaemia and frank haemorrhage
  • Recurrent aspiration pneumonia when stricture formation is present
  • Perforation of peptic ulcer
  • Pyloric stenosis