Gastric Erosion Symptoms and Management
Typical Clinical Presentation
Gastric erosions typically present with recurrent upper gastrointestinal symptoms that are clinically indistinguishable from peptic ulcer disease, including epigastric pain, upper abdominal discomfort, and in some cases gastrointestinal bleeding. 1
Key Symptoms to Identify:
- Recurrent epigastric or upper abdominal pain - This is the hallmark distinguishing feature compared to controls, with recurrent symptoms being significantly more common in erosion patients 2
- Upper gastrointestinal bleeding - May manifest as hematemesis, melena, or occult blood loss, occurring in approximately one-third of symptomatic cases 1, 3
- Weight loss - Present in a subset of patients with more severe or chronic disease 1
- Nausea and dyspeptic symptoms - Similar to other acid-peptic disorders 1
Important Clinical Context:
- Recent NSAID or aspirin use is strongly associated with incomplete erosions, particularly in female patients 2, 4
- Smoking is more prevalent among erosion patients compared to controls 2
- Irregular working hours and stress may be contributing factors 2
- Some patients may be completely asymptomatic despite endoscopic evidence of erosive disease, analogous to asymptomatic erosive esophagitis 5
Diagnostic Approach
Endoscopy is the most effective diagnostic examination for gastric erosions and should be performed in patients with alarm symptoms, persistent symptoms despite empirical therapy, or those over the local age cutoff for gastric cancer risk. 3, 6
Endoscopic Findings:
- Target lesions with central erosion and surrounding mucosal elevation (characteristic of chronic erosive/varioliform gastritis) 1
- Multiple erosions with acute and chronic inflammatory changes 1
- Radiologically may appear as typical target lesions on upper GI series 1
Essential Testing:
- H. pylori testing is mandatory, as this is a major determinant of gastritis evolution and treatment strategy - use 13C urea breath test, stool antigen test, or locally validated serology with ≥90% sensitivity/specificity 6, 7
- Complete blood count to assess for anemia from chronic blood loss 6
- Biopsy should be obtained to assess for pseudopyloric metaplasia, pyloric gland hyperplasia, inflammation, and to rule out malignancy (atypia can be present and may be misinterpreted) 1
Management Strategy
Immediate Interventions:
Discontinue all gastric mucosal irritants immediately, including NSAIDs, aspirin, corticosteroids, and oral bisphosphonates. 4
- For patients requiring ongoing antiplatelet therapy, consider switching to acetaminophen for pain control 4
- If NSAID continuation is absolutely necessary, co-prescribe PPI therapy 4
Pharmacologic Treatment:
Start a standard-dose proton pump inhibitor (PPI) once daily, taken 30-60 minutes before the first meal of the day, for 4-8 weeks to achieve initial healing of erosive lesions. 4
PPI Dosing Options:
- Omeprazole 20 mg daily 8
- Lansoprazole 30 mg daily 8
- Esomeprazole 40 mg daily 8
- Pantoprazole 40 mg daily 8
- Rabeprazole 20 mg daily 8
Critical timing: PPIs must be taken before meals to coincide with postprandial peak in active proton pumps for maximum efficacy 4
Long-Term Maintenance:
After initial healing, patients with documented moderate erosive gastritis require continuous daily PPI therapy indefinitely to prevent recurrence of erosive disease. 4, 8
- Daily maintenance dosing is essential - on-demand or intermittent therapy is explicitly contraindicated for erosive disease, as recurrence rates are unacceptably high with less-than-daily dosing 4, 8, 9
- Titrate to the lowest effective dose based on symptom control, but daily dosing must be maintained 4
- PPIs are dramatically superior to H2-receptor antagonists for both healing and maintenance, with patients on H2RAs being up to twice as likely to have recurrent disease 8, 4
H. pylori Management:
If H. pylori testing is positive, eradication therapy is essential, as this is a major determinant of gastritis evolution and will identify most cases of underlying peptic ulcer disease. 6, 7
- In H. pylori-positive patients with erosions, gastritis shows evolution toward antral predominance over time 7
- Eradication prevents progression and reduces recurrence risk 6
- Repeat testing to confirm eradication is not routinely required in uncomplicated cases 6
Adjunctive Lifestyle Modifications:
- Avoid recumbency for 2-3 hours after meals 8, 4
- Limit dietary fat intake to less than 45 grams per day 8, 4
- Avoid individual trigger foods (alcohol, coffee, spicy foods) only if they consistently provoke symptoms 9, 4
- Smoking cessation is strongly recommended 8, 4
- Limit alcohol consumption 8, 4
Follow-Up and Monitoring
Routine endoscopic monitoring to assess disease progression is NOT recommended once healing is achieved. 8, 4
- The indication for long-term PPI therapy should be clearly documented in the medical record 4
- No routine monitoring (bone density, calcium supplementation, H. pylori screening) is required for long-term PPI users 9
- Long-term PPI therapy is safe, with only slight increases in C. difficile colitis and bacterial gastroenteritis, but absolute risks remain small 9
When to Repeat Endoscopy:
- Persistent or worsening symptoms despite adequate PPI therapy 6
- New alarm symptoms (dysphagia, weight loss, persistent vomiting, evidence of GI bleeding) 6
- Suspicion of malignancy based on biopsy findings 1
Critical Pitfalls to Avoid
Common Management Errors:
Never use on-demand or intermittent PPI therapy for documented erosive gastritis - this approach is only appropriate for non-erosive reflux disease and leads to high recurrence rates of erosive lesions 4, 8, 9
Do not substitute H2-receptor antagonists for maintenance therapy - they are significantly less effective than PPIs for preventing recurrence 4, 8
Do not prescribe twice-daily PPI dosing as initial therapy - it lacks FDA approval and proven benefit for erosive gastritis while increasing costs unnecessarily 4
Do not discontinue PPIs in patients with healed erosive gastritis without understanding that recurrence is highly likely and continuous therapy is the standard of care 4, 8, 9
Do not misinterpret biopsy atypia as malignancy - atypia can be present in chronic erosive gastritis and has been incorrectly interpreted as intramucosal carcinoma 1
Do not fail to test for H. pylori - this is a major determinant of disease evolution and treatment success 6, 7
Special Populations:
For bleeding erosions associated with surgery and sepsis (stress-related), more aggressive management may be required, including consideration of endoscopic hemostasis or, historically, gastric cooling in refractory cases. 3