Can acute gastritis cause abdominal pain and projectile vomiting?

Can Acute Gastritis Cause Abdominal Pain and Projectile Vomiting?

Yes, acute gastritis can cause both abdominal pain and vomiting, though projectile vomiting is not a typical or defining feature of uncomplicated gastritis. The clinical presentation depends on the severity and type of gastritis, with more severe forms like acute phlegmonous gastritis presenting with severe abdominal pain and vomiting as prominent symptoms.

Clinical Presentation of Acute Gastritis

Typical Symptoms

• Abdominal pain is a cardinal feature of acute gastritis, typically localized to the epigastric region 1, 2.
• Nausea and vomiting occur commonly in acute gastritis, though the vomiting is typically not described as "projectile" in uncomplicated cases 1, 2.
• In acute hemorrhagic gastritis, patients may present with upper gastrointestinal bleeding, which can manifest as hematemesis (coffee-ground emesis) or melena 3.

Severe Forms Requiring Urgent Attention

Acute phlegmonous gastritis represents a rare but severe bacterial infection of the gastric wall that presents with:

• Severe upper abdominal pain 4, 5, 6
• Vomiting and complete anorexia 6
• High fever and septic shock symptoms 4
• Diffuse thickening of the gastric wall on imaging 4, 5

This condition requires immediate recognition because it can progress to gastric perforation and carries high mortality without prompt treatment 4.

Important Clinical Distinctions

When Projectile Vomiting Suggests Alternative Diagnoses

Projectile vomiting with severe abdominal pain should raise concern for more serious conditions:

• Bowel obstruction: Presents with intermittent acute abdominal pain, vomiting, and inability to pass gas or stool 1
• Acute mesenteric ischemia: Characterized by severe abdominal pain out of proportion to physical findings, with nausea and vomiting occurring in 35-44% of patients 7, 8
• Perforated peptic ulcer: Presents with sudden severe epigastric pain, vomiting, and signs of peritonitis 8

Red Flags Requiring Immediate Evaluation

The following features suggest complications or alternative diagnoses requiring urgent intervention:

• Fever and tachycardia with epigastric pain suggest potential perforation (mortality up to 30%) 2
• Occult blood in stool indicates gastrointestinal bleeding, the most common complication of peptic ulcer disease 2
• Signs of peritonitis (abdominal rigidity, rebound tenderness) mandate immediate surgical consultation 2
• Cardiovascular instability or septic shock symptoms suggest severe phlegmonous gastritis or other life-threatening conditions 4

Diagnostic Approach

Initial Assessment

• Epigastric pain with heartburn, regurgitation, nausea, and vomiting suggests gastroesophageal reflux disease, esophagitis, peptic ulcer disease, or gastritis 1.
• Upper endoscopy is the first-line diagnostic investigation for suspected peptic ulcer disease or gastritis 2.
• In patients with severe symptoms, fever, or signs of complications, computed tomography may reveal gastric wall thickening, perforation, or alternative diagnoses 4, 5.

Laboratory Findings

• Leukocytosis may be present in severe gastritis or complications 4
• Elevated lactate levels (>2 mmol/L) suggest bowel ischemia rather than simple gastritis 7, 8

Management Considerations

For uncomplicated acute gastritis:

• Treatment includes proton pump inhibitors and supportive care 4
• Antibiotics are reserved for specific bacterial infections like Helicobacter pylori or phlegmonous gastritis 4, 5

For severe or complicated cases:

• Acute phlegmonous gastritis may be successfully treated with antibiotics alone if diagnosed early 5
• Surgical intervention (gastrectomy) is reserved for cases with perforation, ongoing bleeding despite medical therapy, or failure of conservative management 4, 3

Clinical Pitfall

The most critical error is dismissing severe epigastric pain with vomiting as "just gastritis" without considering life-threatening alternatives. While gastritis can cause these symptoms, the presence of projectile vomiting, severe pain, fever, hemodynamic instability, or peritoneal signs should prompt immediate evaluation for bowel obstruction, mesenteric ischemia, perforation, or severe phlegmonous gastritis 1, 7, 8, 4.