Review Question - QID 101152

The clinical presentation is consistent with type B chronic gastritis, most commonly due to H. pylori infection, which should be treated with a combination of acid suppression and antibiotics.

Type B chronic gastritis involves the antrum and pylorus of the stomach and is commonly caused by H. pylori; whereas, type A involves the fundus and body of the stomach and is commonly caused by an auto-immune response to the parietal cells. The bacteria do not invade the stomach lining, but rather cause chronic inflammation. Testing for H. pylori includes the non-invasive urease breathe test and H. pylori stool antigen, which both signal current infection, or endoscopic biopsy. When H. pylori is thought to be the causative agent, "triple therapy" - omeprazole, clarithromycin and amoxicillin - is used as treatment. Untreated H. pylori is associated with an increased risk of peptic ulcer disease and gastric cancers such as adenocarcinoma and MALT lymphoma. NSAID use is also associated with Type B chronic gastritis.

Pezzi et al. report that although a causative role in gastric cancer has not been proven, evidence suggests an association between H. pylori infection and well-differentiated gastric adenocarcinoma and gastric lymphoma.

Wilkins et al. note that upper GI bleeding is most commonly associated with the use of NSAIDs and H. pylori. They recommend undergoing an endoscopy within 24 hours of an upper GI bleed, as it confirms the diagnosis and allows for targeted therapy, such as epinephrine injection, thermocoagulation, application of clips, and banding.

Figure A reveals Gram negative curved rods in the gastric epithelium.

Incorrect Answers
Answer 1: Sulfasalazine and corticosteroid therapy would be indicated in patients with inflammatory bowel disease.
Answer 2: Gluten free diet would be recommended for patients with Celiac disease.
Answer 4: Intramuscular intrinsic factor injection would be indicated in Type A chronic gastritis, which is characterized by the presence of autoantibodies directed against the patient's parietal cells. The lack of intrinsic factor can lead to megaloblastic anemia if not corrected.
Answer 5: NSAIDs that target cycloxygenase-1 are associated with chronic gastritis. COX-2 inhibitors (celecoxib) have been shown to have less gastrointestinal side effects than COX-1 inhibitors and H. pylori infection is more likely a cause for this patient's gastritis given the presence Gram negative rods on biopsy .