Stress-Induced Gastritis - Causes, Symptoms, Diagnosis, and Treatment

Introduction:

The dysregulation in the secretion of gastric acid, the neurotransmitter acetylcholine (ACH), gastrin, and histamine results in hemorrhagic or erosive gastropathy, known as stress gastritis. Gastric erosions are known as curling ulcers. The initial step in developing stress-induced gastritis is decreased mucosa resistance from toxic radicals. The most common symptom is bleeding, followed by persistent nausea with epigastric pain. Stress-induced gastritis can be treated primarily with proton pump inhibitors and the use of histamine blockers later.

How to Regulate Hydrogen Ion Secretion?

Gastric acid is produced when gastric pH stimulates the release and activation of various digestive enzymes. This gastric acid is essential for food digestion breakdown of nutritional components into absorbable carbohydrates, fats, and amino acids. The pH of the stomach is acidic concerning the surrounding. So gastric acid performs its functions in the stomach. The pH is maintained acidic by the secretion of hydrogen ions by the parietal cells located in the fundus of the stomach.

The substances which stimulate hydrogen ion secretion are:

• Gastrin is a hormone that stimulates hydrogen ion secretion via the phospholipase pathway, leading to the activation of the hydrogen/potassium ATPase enzyme. Gastrin is secreted through the G-cells, which are present in the antrum of the stomach.

• Neurotransmitter acetylcholine (ACH) stimulates the parietal cell through the same phenomena as gastrin, the phospholipase pathway.

• Histamine encourages the parietal cells via the cAMP pathway to secrete hydrogen ions. It is secreted by the mast cells present in the surrounding gastric tissue.

What Are the Causes of Stress-Induced Gastritis?

Physiologic stress can alter the pH and disrupt hemostatic digestion, leading to gastric pH irregularities. In such stressed conditions, the elevated levels of histamine and ACH (neurotransmitter acetylcholine) cause increased acid production, thus inducing gastritis. This causes inflammation of the stomach.

• Patients in the surgical (ICU) intensive care unit or recent surgery cases are prone to physiological stress. This stress can be related to severe burns, intense trauma, ventilator dependency for a prolonged time, and intracranial trauma.

• Stress-induced gastritis decreases the resistance of mucosa from toxic radicals and decreases gastric renewal, which causes atrophy of gastric mucosa. Gradually blood flow to the stomach falls off, making the stomach more susceptible to hyperacid secretion and acid-pepsin ulceration.

What Are the Symptoms of Stress-Induced Gastritis?

• Patient Discomfort and Melanotic Stools: Due to increased acid secretion, there is the development of erosion that can cause hemorrhages. These hemorrhages lead to melanotic stools. Initially, the bleeding is not threatening but gets severe after four to five days.

• Persistent nausea with pain in the epigastric region of the abdomen.

• Oxidative Stress on the Mucosa: Stress leads to the release of angiotensin- II, which contributes to blood flow reduction in the mucosa. This reduced blood flow results in reactive oxygen species formation, which attacks DNA and results in 8- hydroxydeoxyguanosine formation. This 8- hydroxydeoxyguanosine leads to mutation and oxidative stress on the mucosa.

• A rare symptom of stress-induced gastritis is perforation. It can be noticed only in approximately 10 % of cases.

• Hematemesis: Expel blood from the mouth. It is a serious condition.

• Melena: Dark stools with or without the presence of blood.

• Coffee Ground Vomitus: The vomit resembles coffee grounds. It occurs due to coagulated blood in the vomit.

• Orthostasis: A normal physiological response to act against a fall in blood pressure when a person acquires an upright position after lying down.

• Abdominal pain and nausea.

• Curling Ulcers: Gastric erosions due to stress gastritis lead to ulcers called curling ulcers.

How to Diagnose Stress-Induced Gastritis?

• Presence of Blood in Nasogastric Tube: When a nasogastric tube is placed and flushed with saline, the returned fluid can be blood. This helps to rule out upper gastrointestinal bleeding.

• Fecal Occult Blood Test (FOBT): This lab test helps investigate hidden blood (occult) in the stool.

• Endoscopy: It gives a definitive diagnosis of stress-induced gastritis.

What Is the Treatment of Stress-Induced Gastritis?

• Proton Pump Inhibitors: It helps to reduce hydrogen ion secretion irrespective of levels of gastrin and acetylcholine in the body. It is an irreversible inhibitor of hydrogen/potassium ATPase. Common proton pump inhibitors are Pantoprazole, Omeprazole and Lansoprazole.

• H2 Blockers: It inhibits the histamine-mediated stimulation of parietal cells and does not directly affect hydrogen/potassium ATPase. Some of the H2 blockers are Ranitidine, Cimetidine, and Famotidine.

• It is advised in critically ill patients that PPIs and H2 blockers should be administered early to prevent stress-induced gastritis.

Which Are Similar Diseases to Stress-Induced Gastritis?

• Gastroesophageal Reflux Disease (GERD): Acid reflux irritates the esophagus and stomach lining.

• Peptic Ulcer Disease: Open sores on the inner lining of the stomach and duodenum.

• Gastroparesis: A condition that affects muscle motility of the stomach.

• Dyspepsia: A condition of pain or discomfort in the upper abdomen region, often after food intake or drinking.

• Alcoholic Gastropathy: Alcohol-induced rupture of the gastric mucosal barrier. It occurs in individuals with alcohol/wine as an integral part of their diet.

• Uremic Gastropathy: Gastrointestinal mucosal lesions induced in uremic patients or lining with chronic kidney disease or end-stage renal disease.

• Gastric or Esophageal Cancer: Any malignant lesion in the tissue or lining of the stomach and intestine can cause bleeding and severe ulcerations.

• NSAID (Nonsteroidal Anti-Inflammatory Drug)-Induced Gastritis: Prolonged exposure of stomach and gastric lining to NSAIDs can cause inflammation and ulceration.

What Are the Complications Caused by Stress-Induced Gastritis?

• Anemia: Excessive blood loss due to ulceration and hemorrhage can lead to anemia.

• Perforations: Increased acid concentration can cause severe ulceration in the gastric lining, which can further lead to perforations.

• Peritonitis: Inflammation of the peritoneum, which covers the organs of the abdomen and lines the inner abdominal wall.

• Gastrocolic fistula because of ulcer perforation.

• Hemorrhagic shock.

• Death.

Conclusion:

Stress-induced gastritis is a disorder of the stomach lining caused due to excessive gastric acid secretion. It is not a life-threatening condition but, if left untreated, can cause several complications. The treatment of choice is medical therapy with proton pump inhibitors and H2 blockers.