Gastritis is any inflammatory process of the mucosal lining of the stomach. The inflammation may be contained within one region or be patchy in many areas. Gastric structure and function are altered in either the epithelial or the glandular components of the gastric mucosa. The inflammation is usually limited to the mucosa, but some forms involve the deeper layers of the gastric wall. Gastritis is classified into acute and chronic forms.
ACUTE. The most common form of acute gastritis is acute hemorrhagic gastritis, also called acute erosive gastritis. The gastric erosions are limited to the mucosa, which have edema and sites of bleeding. Erosions can be diffuse throughout the stomach or localized to the antrum.
CHRONIC. The three forms of chronic inflammation of the gastric mucosa are superficial gastritis, atrophic gastritis, and gastric atrophy. Superficial gastritis, the initial stage in the development of chronic gastritis, leads to red, edematous surface epithelium, small erosions, and decreased mucus content. The gastric glands remain normal. With atrophic gastritis, inflammation extends deeper into the gland area of the mucosa with loss of parietal and chief cells. Atrophic gastritis further develops into the final stage of chronic gastritis—gastric atrophy. In this stage, there is a total loss of glandular structure.
Chronic gastritis has also been classified as type A and type B. Type A chronic gastritis, the less common form, involves the body of the stomach (fundus) rather than the antrum. Type B gastritis is a more common nonautoimmune inflammation of the lining of the stomach. It primarily involves the antrum but can affect the entire stomach as age increases. Patients with chronic gastritis have an increased risk (10%) for gastric cancer or may develop chronic iron deficiency. Untreated gastritiscan also lead to hemorrhage and shock, gastric perforation, gastrointestinal (GI) obstruction, and peritonitis. Alkaline reflux gastritis is inflammation caused by reflux of bile and pancreatic secretions that disrupt the mucosal layer of the stomach and lead to burning epigastric pain, nausea, and emesis. Alkaline reflux gastritis is a known compliction of the Billroth II gastrojejunostomy surgical procedure.
Causes of Gastritis
ACUTE GASTRITIS. Alcohol abuse or ingestion of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) are the most common causes. Other causes are steroid or digitalis medications; ingestion of corrosive agents such as lye or drain cleaners; ingestion of excessive amounts of tea, coffee, mustard, cloves, paprika, or pepper; chemotherapy or radiation to the upper abdomen; severe stress that is related to critical illness; staphylococcus food poisoning; infections (candida, cytomegalovirus, herpesvirus) in immunosuppressed patients; and Helicobacter (H) pylori in chronic gastritis.
CHRONIC GASTRITIS. Type A gastritis is considered primarily an autoimmune disorder. The primary cause of type B gastritis is H. pylori, which is found in nearly 100% of the cases of type B gastritis. In both acute and chronic type B gastritis, the normal gastric mucosal barrier is disrupted, which leads to mucosal injury.
Nursing care plan assessment and physical examination
Obtain a detailed history of past illnesses, as well as the onset, duration, and aggravating and relieving factors of any symptoms. Common symptoms include epigastric pain, changes in stool color, nausea and vomiting (emesis may be bright red, coffee ground, or bile colored), and appetite and weight changes. Assess the patient’s usual daily diet, including alcohol, tea, and coffee ingestion. Obtain a complete medication profile that includes both prescribed and over the-counter (OTC) drugs. Patients with gastritis may have only mild epigastric discomfort or intolerance for spicy or fatty foods. Patients with atrophic gastritis may be asymptomatic.
The patient may appear normal or may seem to be in discomfort, with facial grimaces and restlessness. Inspect for signs of dehydration or upper GI bleeding, which may be the only sign of acute gastritis. Bleeding can range from a sudden hemorrhage to an insidious blood loss that can be detected only by stool guaiac testing for occult blood or an unexplained anemia. Pallor, tachycardia, and hypotension occur with dramatic GI bleeding accompanied by hematemesis and melena.
Auscultate for decreased bowel sounds, which may or may not accompany gastritis. Palpate the abdomen to evaluate the patient for distension, tenderness, and guarding. Epigastric pain and abdominal tenderness are usually absent with patients who have GI bleeding. Gastritis that is caused by food poisoning and corrosive agents (ingestion of strong acids) results in epigastric pain, nausea, and vomiting.
Assess the patient’s and family’s anxiety and ability to cope with the fears that are associated with hemorrhage. Assess the patient’s understanding of disease management and his or her coping abilities to participate in lifestyle modifications.
Nursing care plan primary nursing diagnosis: Altered nutrition: Less than body requirements related to decreased appetite, food intolerance, vomiting.
Nursing care plan intervention and treatment
The immediate treatment for acute gastritis is directed toward alleviating the symptoms and withdrawing the causative agents. The physician usually prescribes an H2 antagonist. The medical goal is to maintain the pH of gastric contents above 4.0. Acute hemorrhagic gastritis may disappear within 48 hours because of rapid cell proliferation and restoration of gastric mucosa. If the bleeding is profuse and persistent, blood replacement is necessary. An infusion of vasopressin (Pitressin) or embolization of the left gastric artery is used to halt hemorrhage. Surgical intervention is not performed unless hemorrhage is uncontrollable. In this rare situation, vagotomy with pyloroplasty is usually performed.
There is no known treatment that will reverse the pathogenesis of chronic gastritis. Eradication of H. pylori bacteria halts active gastritis in approximately 92% of the cases unless there is permanent damage to the gastric epithelium. The medical regimen for eradicating H. pylori is a combination of bismuth salts and two antibiotics over a 2-week period. An important part of management of patients with chronic gastritis is long-term follow-up for early detection of gastric cancer. Patients who have either chronic type A or B gastritis may develop pernicious
anemia; destruction of parietal cells in the fundus and body of the stomach leads to inadequate vitamin B12 absorption.
Encourage the patient to avoid aspirin and NSAIDs (indomethacin and ibuprofen) unless they have been prescribed. Reinforce the need to take these medications with food or to take entericcoated aspirin. Other drugs that may contribute to gastric irritation include chemotherapeutic agents, corticosteroids, and erythromycin. Explain the importance of reading the labels of OTC drugs to identify those that contain aspirin. Instruct the patient about the action, dosage, and frequency of the medications (antacids, H2 antagonists, antibiotic regimen) that are administered while the patient is in the hospital. Discuss the possible complications that can develop with acute or chronic gastritis (hemorrhage, pernicious anemia, iron deficiency anemia, or gastric cancer). Explain the pathophysiology and treatment of each possible complication. Discuss how ingestion of caffeine and spicy foods results in irritation and inflammation of the mucosa of the stomach.
Be sure the patient understands how smoking and alcohol aggravate gastritis and that abstaining from both will facilitate healing and reduce recurrence. Provide information about various smoking and alcohol rehabilitation programs available in the community. Explain the rationale for the need for support during this very difficult lifestyle change for permanent abstinence.
Assist the patient in identifying her or his personal physical and emotional stressors. Review coping skills that the patient has used previously to change behaviors. Talk about how to adapt the environment to which the patient must return in order to meet the needs of lifestyle changes. Involve the family in assisting with the patient’s needed changes. Assess the family’s response and ability to cope.
Nursing care plan discharge and home health care guidelines
Instruct the patient to avoid caffeine drinks, hot and spicy foods, identified aggravating foods, alcohol, smoking, salicylates, and NSAID OTC drugs. Provide a written list of symptoms of GI bleeding and pernicious anemia (weakness, sore tongue, numbness and tingling in the extremities, anorexia, weight loss, angina, shortness of breath, palpitations). Inform the patient of the need for lifetime vitamin B12 intramuscular injections if pernicious anemia develops. Reinforce the need for follow-up for early detection testing for gastric cancer. Review medication action, dosage, frequency, and side effects. Make referrals to smoking and alcohol cessation programs of the patient’s choice. Reinforce relaxation exercises and stress management techniques.