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

Differentiating and Managing Erosive Gastritis versus Peptic Ulcer Disease

Endoscopy is the gold standard for differentiating between erosive gastritis and peptic ulcer disease, with erosive gastritis presenting as multiple small erythematous nodules with shallow central erosions, while peptic ulcers appear as deeper, well-demarcated breaks in the mucosa. 1

Diagnostic Differences

Endoscopic Findings

• Erosive Gastritis:

  • Multiple small erythematous nodules (3-11mm)
  • Shallow central erosions
  • Often distributed along rugal folds extending into the antrum 1, 2

• Peptic Ulcer:

  • Single or few deeper lesions
  • Well-demarcated breaks in the mucosa
  • Extends deeper than the muscularis mucosae 1

Radiological Findings

• Erosive Gastritis: Series of small nodules (3-11mm), some with central collections of barium 2
• Peptic Ulcer: Single crater or niche 1

Histopathological Differences

• Erosive Gastritis:

  • Predominance of plasma cells in inflammatory infiltrate
  • Pseudopyloric metaplasia
  • Pyloric gland hyperplasia
  • Minimal polymorphonuclear leukocytes 3, 2

• Peptic Ulcer:

  • Deeper tissue destruction
  • More acute inflammatory changes 1

Management Approach

First-Line Treatment

1. Erosive Gastritis:

   • Standard dose PPI once daily (e.g., omeprazole 20mg) for 4-8 weeks 1
   • Take PPI 30-60 minutes before meals
   • Lifestyle modifications:
     • Weight management
     • Avoiding trigger foods
     • No meals within 3 hours of bedtime
     • Elevating head of bed 1

2. Peptic Ulcer Disease:

   • Standard dose PPI once daily for:
     • 4-8 weeks for duodenal ulcers
     • 8 weeks for gastric ulcers
   • Mandatory H. pylori testing and eradication if positive 1
   • Triple therapy for H. pylori eradication

Special Considerations

• NSAID-Related Cases:

  • Discontinue NSAIDs for both conditions
  • If NSAIDs must be continued, add PPI for gastroprotection 1

• Bleeding Management:

  • Erosive gastritis: Usually responds to conservative treatment
  • Peptic ulcer bleeding: May require endoscopic intervention (injection, thermal, or mechanical therapy) 1

Follow-Up and Monitoring

• Erosive Gastritis:

  • Symptom resolution is common with treatment
  • Endoscopic lesions may persist even after symptom resolution 2
  • Maintenance therapy with lowest effective PPI dose based on symptom control 1

• Peptic Ulcer:

  • Gastric ulcers require follow-up endoscopy to confirm healing and rule out malignancy
  • Duodenal ulcers generally don't require follow-up endoscopy unless complications occur 1

Common Pitfalls to Avoid

1. Misdiagnosis: Atypia in erosive gastritis can be incorrectly interpreted as intramucosal carcinoma 1, 3

2. Undertreating peptic ulcers: Failing to test for and treat H. pylori 1

3. Overtreatment: Using twice-daily PPI for erosive gastritis before trying standard dosing 1

4. Inadequate follow-up: Not confirming healing of gastric ulcers, which could be malignant 1

5. Missing coexistence: Duodenal erosions may occur with gastric erosions or ulcers, contributing to bleeding 4

Refractory Cases

• Increase to twice-daily PPI dosing
• Consider adding H2-receptor antagonists for nighttime acid breakthrough
• Diagnostic testing with pH monitoring to confirm acid-related etiology 1