Gastritis with Case

00:01 So now we'll move to our next case.

00:03 We have a 48-year-old man who presents to the clinic for follow-up.

00:07 He has had four months of epigastric discomfort and abdominal bloating after meals.

00:13 He has tried twice-daily omeprazole for the last three months without relief.

00:18 He has no weight loss, dysphagia, or odynophagia. He recently moved here from Mexico.

00:24 And two weeks ago, he underwent an upper endoscopy that showed erythema and erosions of the gastric mucosa.

00:32 One biopsy is taken shown here. His vitals are normal.

00:38 On exam, abdominal exam is benign.

00:41 So we're asked, what is the best next step in management? Before we answer that question, let's look a bit closer at this case.

00:49 So he has chronic epigastric discomfort after eating, he has already tried a greater than eight-week trial of a proton pump inhibitor, he importantly moved from a developing country, and he has some suspicious endoscopy results shown here that we'll go into a bit later.

01:10 So let's talk now about gastritis. Gastritis is the clinical term we use to refer to inflammation of the gastric mucosa.

01:20 When there is cell damage without inflammation, this is just called gastropathy.

01:26 So gastritis can result from multiple causes. It has a similar list of risk factors as peptic ulcer disease.

01:35 So things like NSAID, H. pylori, smoking, and alcohol can all cause gastritis.

01:41 It may also be an autoimmune condition, it can be results of infections, and it can also be due to granulomatous disease like Crohn's disease or sarcoidosis.

01:53 So here you can see two examples of biopsies from the gastric mucosa.

01:58 In panel B, you see a normal gastric mucosa.

02:02 And in panel A, you see multiple cells that are mononuclear infiltrating the gastric mucosa.

02:09 And this is what it looks like when patients have gastritis.

02:13 So the diagnosis of gastritis is made by upper endoscopy that should be done if patients continue to have symptoms after an adequate trial of a proton pump inhibitor or H2 blocker.

02:26 They should also be tested at some point for H. pylori or any other suspected infections.

02:33 Treatment is done by targeting the underlying cause.

02:36 So in summary, when you see a patient who's coming to you with gastritis, you should always remember to test for H. pylori, stop any offending agents, give them a trial of a proton pump inhibitor or H2 blocker, and then if they still have symptoms after eight weeks, refer for upper endoscopy.

02:56 So now let's go back to our case.

03:00 We had a 48-year-old man coming in with chronic epigastric discomfort after eating, he has already tried an adequate trial of PPI, he interestingly moved from a developing country, and his endoscopy results that we discussed earlier now show gastritis as you can see multiple lymphocytes infiltrating into the mucosa.

03:21 What is the best next step in diagnosis? So since this patient is from a region where H. pylori has high prevalence, he should have had gastric biopsies done to rule out H. pylori.

03:35 But since this is not shown in the example that we are given, you should check for an H.pylori stool antigen.