أسئلة الـ Gastritis & Gastric Polyps

• Gastritis and gastric polyps are the topics for this presentation.
• The agenda includes an introduction case, gastritis, and gastric polyps.

Introduction Case

• A 52-year-old man is presenting with decreased appetite, frequent belching, unintentional weight loss of 8 pounds over two months, and intermittent epigastric pain that worsens after meals
• The diet consists of red meat and spicy food
• The patient smokes half a pack of cigarettes and drinks 1-2 beers daily while not taking NSAIDs
• The medical history is unremarkable
• There is tenderness upon physical examination in the epigastric region
• An upper endoscopy shows hyperemia, enlargement of mucosal folds, and nodularity in the gastric antrum and body
• A biopsy shows chronic active gastritis with glandular atrophy and spiral-shaped bacteria in the gastric epithelium
• Next steps in management are to be determined

Definition of Gastritis

• Inflammation of the stomach lining associated with mucosal injury
• It is primarily a histological diagnosis confirmed through biopsy
• Typically caused by infectious agents like Helicobacter pylori, autoimmune responses, or hypersensitivity reactions
• Onset can be sudden and short-lived, or it can be prolonged, leading to severe complications

Chronologic Classification of Gastritis

• Acute gastritis signifies a short term infection of the stomach lining, triggered by excessive alcohol, stress, or medications, and characterized by acute symptoms
• Chronic gastritis indicates a long-term inflammation within the stomach, often linked to bacterial infections like helicobacter pylori or autoimmune disorders, and characterized by mild or potentially no symptoms
• Acute gastritis can present with severe symptoms like abdominal pain, nausea, and vomiting, while chronic gastritis may present with only mild or no apparent symptoms
• Treatment for acute gastritis includes antacids, PPIs, or H-2 blockers, contrasting with chronic gastritis, which requires antibiotics, PPIs, or H-2 blockers, along with medications, to address the underlying disease
• Acute gastritis resolves without significant complications; chronic gastritis can lead to stomach ulcers or heightened cancer risk
• Acute gastritis carries a minimal mortality rate, while chronic gastritis has moderate to high mortality, depending on the underlying condition

Aetiologic Classification of Gastritis

• Non-atrophic gastritis is etiologically linked to Helicobacter pylori
• Atrophic gastritis:
  • Autoimmune-related is due to autoimmunity.
  • Multifocal atrophic originates from H. pylori and environmental insults.
• Special forms of Gastritis include:
  • Chemical-induced arises from NSAIDs, bile, amongst other agents
  • Radiation-induced is caused by radiation injury.
  • Lymphocytic type is a result of gluten sensitivity or celiac disease
• Non-infectious granulomatous gastritis stems from Crohn's disease and sarcoidosis cases
• Eosinophilic gastritis is due to food sensitivity
• Other infections can come from bacteria other than H. pylori, viruses, and fungi

Clinical Presentations of Gastritis

• Common symptoms of gastritis are epigastric pain (gnawing or burning), nausea and vomiting, anorexia and dyspepsia, and belching
• Critical alarm symptoms or red flags include age > 55 years, anemia, bleeding, weight loss, recurrent vomiting, early satiety, and a family history of GI cancer

Investigations of Gastritis

• Lab tests include H. pylori testing, serum gastrin, CBC for parietal cell antibody (PCA), and intrinsic factor antibody (IFA) to diagnose gastritis
• Endoscopy and biopsy are used according to algorithms to determine the cause of gastritis

Endoscopic Pictures & Biopsy Sites of Gastritis

• Endoscopic findings can vary including erythematous, erosive, hemorrhagic, atrophic, hypertrophic, and nodular
• The Sydney system is used to perform gastric biopsies when evaluating gastritis and includes sites 1 and 2 (antrum), site 3 (angulus), site 4 (middle body LC), and site 5 (middle body GC)
• Ménétrier's Disease includes foveolar hyperplasia, large tortuous gastric mucosal folds, protein losing gastropathy, and decreased gastric acid output
• Ménétrier's Disease is most prominent in the body and fundus and is TGF-mediated
• There is an increased risk of adenocarcinoma stomach
• Treatment for Ménétrier's Disease is anticholinergics, prostaglandins, PPI's, and prednisone

Gastric and Extragastric Complications of Chronic Gastritis

• Type A chronic gastritis (fundus/body) is autoimmune with autoantibodies to parietal cells, leading to pernicious anemia and achlorhydria
• Type B chronic gastritis (antrum) is caused by H. pylori infection
• Chronic gastritis can lead to normal mucosa, chronic active gastritis, gastric atrophy, intestinal metaplasia, dysplasia, and gastric cancer

Treatment of Gastritis

• PPI ± eradication of H. pylori is the cornerstone treatment
• Provides symptomatic treatment for functional dyspepsia
• Treat the underlying cause

Definition and Symptoms of Gastric Polyps

• Gastric polyps are distinct intraluminal protrusions of mucosal or sub-mucosal tissue above the mucosal surface
• The term comes from the Greek words "polypus" (many-footed) and "gastric" (stomach)
• It is merely descriptive and does not define a specific etiology
• Gastric polyps are typically asymptomatic and small, often found incidentally during endoscopic examinations for unrelated conditions, such as anemia or gastrointestinal hemorrhage

Classification of Gastric Polyps

• Neoplastic polyps include adenomatous carcinoma (primary or metastatic) and carcinoid tumors
• Hyperplastic or inflammatory polyps are usual (gastritis-related), polypoid hyperplasia near sites of repair such as stomas or ulcers, or inflammatory fibroid polyps
• Hamartomatous or developmental polyps include fundic-gland polyps and pancreatic heterotopia
• Mesenchymal polyps include gastrointestinal stromal tumors and neural tumors (Schwannoma/neuroma, ganglioneuroma, granular-cell tumors)
• Miscellaneous polyps include xanthoma, lymphoma, and hemangioma

Examples of Gastric Polyps

• Fundic Gland Polyps:
  • Most common in Western countries, typically numerous, small at less than 1 cm, smooth, hyperemic, and found in the fundus or body
  • NBI shows a honeycomb appearance with dense vasculature
  • Can be either sporadic (long term PPI) or familial (FAP)
  • Rare dysplasia if sporadic, there is increased risk in syndromic
  • Resect if > 1 cm or dysplasia
  • Biopsy at first EGD or if atypical features/location
• Gastric Adenoma:
  • Usually solitary within the antrum but can arise anywhere, NBI is not well-defined
  • Associated with chronic atrophic gastritis and GIM
  • Subtypes: intestinal, foveolar, pyloric gland, oxyntic
  • High risk or synchronous cancer, examine thoroughly
  • Resect ALL
  • Surveillance EGD after resection at least 1 year
• Hyperplastic Polyp
  • Smooth, red, whitish mucinous exudates, sessile or pedunculated, often multiple, usually in the antrum but can be anywhere
  • NBI shows prominent vascular pattern
  • Associated with chronic gastritis
  • Higher malignant potential for large >1 cm + pedunculated
  • Sample surrounding the mucosa
  • H. pylori eradication eliminates 70%

Complications of Gastric polyps

• Bleeding
• Perforation
• Infection
• Tumors & Cancer
• Obstruction

Endoscopic Treatment of Gastric Polyps

• Biopsy and en-bloc resection are a necessary treatment method
• Endoscopic mucosal resection (EMR) is recommended for lesions greater than 10 mm due to the correlation between lesion size and malignant potential
• IV PPI is given to promote hemostasis and lessen environmental acidity before any mucosal treatment
• Oral PPI is used frequently for 4-8 weeks after endoscopy with biopsy to promote healing at the biopsy/resection sites
• If pathology indicates helico pylori infection, antibiotic therapy is started
• To ascertain the cause of gastritis involving the mucosa the endoscopist must perform a biopsy to the rest of the stomach
• Histopathologic results of the polyps removed during EGD serve as guidance for management and for follow-up

Surveillance of Gastric Polyps

• For H. pylori in gastric polyp biopsy:
  • Use antibiotic therapy.
  • Repeat EGD in 3-6 months for a repeat biopsy to confirm the eradication of infection and monitor polyp regression
• For Fundic polyps:
  • Stop PPI as soon as possible.
  • A 1-year follow-up EGD monitors response to therapy and watch lesions larger than 5 to 10 mm on the first EGD.
• For Adenoma:
  • A 1-year follow-up.
• For FAP:
  • If a patient under 40 has adenomas, colonoscopy, or family history of a thorough family history advised to rule out familial adenomatous polyposis.
  • Microscopy reveals dysplasia. Repeat endoscopy 1 year after original endoscopy and again 3 years later.