What is the appropriate management for a patient with acute gastritis?

Management of Acute Gastritis

For acute gastritis, prioritize supportive care with acid suppression therapy (proton pump inhibitors or H2 receptor antagonists), identify and eliminate causative factors (NSAIDs, alcohol, stress), and assess for H. pylori infection requiring eradication therapy if present.

Immediate Management and Supportive Care

Identify and Remove Causative Factors

• Discontinue NSAIDs immediately if they are the suspected trigger, as NSAID use is a major predisposing condition for hemorrhagic gastritis 1
• Eliminate alcohol consumption, which is a well-established cause of acute hemorrhagic gastritis 1
• Address physiologic stress in hospitalized patients, particularly those in ICU settings with severe life-threatening disease or trauma 1

Acid Suppression Therapy

• Initiate proton pump inhibitors (PPIs) or H2 receptor antagonists as first-line pharmacologic therapy, using the same approach as for classic peptic ulcer disease 1
• Antacids may be used as adjunctive therapy for symptom relief 2
• These medications promote mucosal healing and reduce gastric acid-related damage 1

Management of Acute Hemorrhagic Gastritis

• Provide aggressive supportive measures including fluid resuscitation and blood product transfusion if bleeding is significant 1
• Consider endoscopic evaluation and therapy, though diffuse mucosal bleeding can make endoscopic hemostasis technically challenging 1
• Reserve surgery as a last resort only for patients with continued bleeding despite aggressive medical and endoscopic therapy 1

Diagnostic Evaluation for Underlying Causes

H. pylori Assessment

• Test all patients with gastritis for H. pylori infection using non-serological testing modalities 3
• If H. pylori positive, administer eradication therapy promptly 3
• Confirm successful eradication using non-serological testing methods after treatment 3
• H. pylori is the dominant etiology of chronic gastritis and can present acutely 4

Distinguish Acute from Chronic/Atrophic Gastritis

• If endoscopy is performed, obtain biopsies from body and antrum in separately labeled jars to assess for atrophic changes 4
• Look for endoscopic features of atrophic gastritis including pale mucosa, increased vascular visibility, and loss of gastric folds 4
• Histopathology is required to confirm atrophic gastritis diagnosis 4

Special Considerations and Pitfalls

Prevention Strategies

• Prevention is the key to management of acute gastritis, particularly in high-risk populations 1
• Provide prophylactic acid suppression in ICU patients and those with physiologic stress 1
• Consider gastroprotection when prescribing NSAIDs to at-risk patients 1

When to Suspect Rare Forms

• Acute phlegmonous gastritis should be considered if there is severe bacterial infection with high fever, severe abdominal pain, and CT showing gastric wall thickening with edema and gas 5
• This rare condition requires immediate broad-spectrum antibiotics and may necessitate emergency total gastrectomy if conservative treatment fails 5

Avoid Common Pitfalls

• Do not rely solely on symptom resolution; address underlying causes to prevent recurrence 1
• Remember that patients with portal hypertension are at higher risk for hemorrhagic gastritis 1
• Be aware that acute gastritis can progress to chronic gastritis if H. pylori infection is left untreated 6

Follow-Up and Long-Term Management

• If atrophic gastritis is identified, evaluate for iron and vitamin B-12 deficiencies 3
• Consider surveillance endoscopy every 3 years for advanced atrophic gastritis 3
• Screen for autoimmune thyroid disease if autoimmune gastritis is diagnosed 3