Causes of Erosive Gastritis
Erosive gastritis is primarily caused by nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin, Helicobacter pylori infection, alcohol, and stress-related mucosal injury, with NSAIDs and aspirin being the most common culprits in clinical practice. 1, 2, 3
Primary Etiologic Factors
NSAID and Aspirin Use
- NSAIDs and aspirin are the leading causes of erosive gastritis through inhibition of prostaglandin synthesis, which normally provides gastroprotection 2, 3
- Nonselective COX inhibition (aspirin, ibuprofen, indomethacin, naproxen) carries significant risk for erosive gastritis and GI bleeding 2
- Distinctive radiographic pattern: Incomplete linear or serpiginous erosions, particularly clustered along the greater curvature of the stomach, are strongly suggestive of aspirin- or NSAID-induced gastritis 3
- Patients at high risk for GI bleeding from ASA/NSAID use require gastroprotection with proton pump inhibitors (PPIs) 1
Helicobacter pylori Infection
- H. pylori is a major pathogenetic factor in erosive gastritis, duodenitis, and gastroduodenitis 4, 5
- Present in approximately 77% of patients with erosive gastritis, with infection being well-manifested in 83% of cases 4
- In H. pylori-positive patients with gastric erosions, gastritis shows evolution toward antral predominance, sharing characteristics of the duodenal ulcer phenotype 5
- H. pylori eradication is indicated as definitive short-term PPI therapy (≤8 weeks) 1, 6
Alcohol
- Alcohol is one of the most frequent etiologic causes of hemorrhagic erosive gastritis 7
- Often presents with epigastric pain and upper GI bleeding 7
Stress-Related Mucosal Injury
- Stress ulcer prophylaxis with PPIs is conditionally indicated for ICU patients with risk factors 1
- Represents acute erosive hemorrhagic gastritis in critically ill patients 8
Less Common Causes
Gastroesophageal Reflux Disease (GERD)
- Erosive esophagitis can lead to GERD-related complications including GI bleeding 1
- Clinically significant erosive esophagitis (Los Angeles Classification grade C/D) requires long-term PPI therapy and should not be considered for PPI discontinuation 1
Immune-Related Causes
- Immune checkpoint inhibitors (e.g., sintilimab) can cause acute erosive hemorrhagic gastritis as an immune-related adverse event 9
- Treatment requires immunosuppressants such as methylprednisolone sodium 9
Multifactorial Pathogenesis
- Changes in intragastric and intraduodenal pressure 10
- Elevated gastric concentrations of biliary acids 10
- Hormonal dysregulation (gastrin, insulin, hydrocortisone, thyroxine, thyrotropine) 10
- Low functional capacity of protective gastric mucus 10
Rare Causes
- Metastatic disease: Invasive lobular carcinoma of the breast can present as erosive gastritis and duodenitis with GI bleeding 11
- Dieulafoy lesion accounts for 1-2% of acute upper GI bleeding 8
Clinical Presentation
Most common symptoms in erosive gastritis include 12:
- Epigastric pain (68.0%)
- Abdominal distension (62.6%)
- Postprandial fullness (47.5%)
Endoscopic findings typically show 12:
- Antral involvement in 72.1% of cases
- Multiple erosive lesions in 51.0%
- Superficial flat lesions in 67.3%
Important Clinical Pitfalls
- Withdrawal of the offending agent (NSAIDs, aspirin, alcohol) leads to marked clinical improvement within several days 3, 7
- Medical treatment is successful in approximately 90% of cases, with surgical intervention showing poor results and high morbidity/mortality 7
- Gastroscopy plays a major role in detection and diagnosis, as symptoms are non-specific 12
- In patients with remote NSAID use presenting with erosive gastritis, consider alternative diagnoses including metastatic disease if biopsy shows signet ring carcinoma 11