How do you differentiate and manage erosive gastritis versus a peptic ulcer?

Differentiating and Managing Erosive Gastritis versus Peptic Ulcer

Erosive gastritis and peptic ulcers require different diagnostic approaches and management strategies, with erosive gastritis typically requiring standard PPI therapy while peptic ulcers often need more aggressive treatment and follow-up based on their depth and etiology.

Key Differences in Pathology

Erosive Gastritis

• Superficial mucosal breaks that do not extend beyond the muscularis mucosa
• Often appear as small erythematous nodules with shallow central erosions
• Typically multiple lesions (3-11mm) distributed along rugal folds
• Pathology shows fewer polymorphonuclear leukocytes and predominance of plasma cells 1, 2
• May present with pseudopyloric metaplasia and pyloric gland hyperplasia 1

Peptic Ulcer

• Deeper lesions that penetrate through the muscularis mucosa into submucosa or deeper
• Usually solitary, well-defined lesions
• More intense inflammatory infiltrate with neutrophils
• Higher risk of serious complications (perforation, significant bleeding)

Clinical Presentation Differences

Erosive Gastritis

• Epigastric pain often occurs after meals
• Sensation of heaviness in epigastrium
• May present with anorexia and weight loss
• Bleeding is typically less severe than with ulcers 1, 3

Peptic Ulcer

• Gnawing or burning epigastric pain
• Pain often improves with food but returns 2-3 hours after eating
• Night pain and heartburn more common
• Higher risk of massive bleeding 4

Diagnostic Approach

1. Endoscopy: The gold standard for differentiating between the conditions

   • Erosive gastritis: Multiple small erythematous nodules with shallow central erosions
   • Peptic ulcer: Single or few deeper, well-demarcated breaks in the mucosa

2. Double-contrast upper GI radiography:

   • Erosive gastritis: Series of small nodules (3-11mm), some with central collections of barium 2
   • Peptic ulcer: Typically shows a single crater or niche

3. Biopsy:

   • Essential to rule out malignancy in gastric ulcers
   • Helps identify H. pylori infection
   • Can confirm histological features of erosive gastritis 1

Management Approach

For Erosive Gastritis:

1. First-line therapy:

   • Standard dose PPI once daily (e.g., omeprazole 20mg daily) for 4-8 weeks 5, 6
   • Take PPI 30-60 minutes before meals 7

2. Lifestyle modifications:

   • Weight management if overweight/obese
   • Avoid trigger foods
   • Avoid meals within 3 hours of bedtime
   • Elevate head of bed 5, 7

3. Maintenance therapy:

   • Titrate to lowest effective dose based on symptom control
   • Consider on-demand therapy for symptom management 5

For Peptic Ulcer:

1. First-line therapy:

   • Standard dose PPI once daily for 4-8 weeks (duodenal ulcer) or 8 weeks (gastric ulcer) 6
   • Test for H. pylori and eradicate if positive with triple therapy:
     • PPI + clarithromycin + amoxicillin for 10-14 days 6

2. Follow-up:

   • Repeat endoscopy to confirm healing for gastric ulcers (to rule out malignancy)
   • Longer duration of therapy may be needed for larger ulcers

3. Maintenance therapy:

   • Continue PPI therapy if high risk of recurrence
   • Consider long-term low-dose PPI for recurrent ulcers 5

Special Considerations

1. H. pylori testing:

   • Essential for all patients with peptic ulcer
   • Consider testing in erosive gastritis, especially if recurrent or refractory

2. NSAID use:

   • Discontinue NSAIDs if possible for both conditions
   • If NSAIDs must be continued, add PPI for gastroprotection

3. Bleeding management:

   • Erosive gastritis bleeding is typically less severe and responds well to conservative treatment 3
   • Peptic ulcer bleeding may require endoscopic intervention (injection, thermal, or mechanical therapy)

4. Refractory cases:

   • For persistent symptoms despite standard therapy, consider:
     • Increasing to twice-daily PPI dosing 7
     • Adding H2-receptor antagonists for nighttime acid breakthrough
     • Diagnostic testing with pH monitoring to confirm acid-related etiology 5, 7

Common Pitfalls to Avoid

1. Misdiagnosis: Atypia in erosive gastritis can be misinterpreted as intramucosal carcinoma 1

2. Undertreating peptic ulcers: Failure to test for and treat H. pylori in peptic ulcer disease

3. Overtreatment: Using twice-daily PPI for erosive gastritis without first trying standard dosing

4. Inadequate follow-up: Not confirming healing of gastric ulcers, which could be malignant

5. Missing other etiologies: Alcohol consumption is a common cause of duodenal erosions 3

By understanding these key differences in pathology, presentation, and management, clinicians can provide appropriate targeted therapy for patients with either erosive gastritis or peptic ulcer disease.