Gastritis

Gastritis is an inflammation of the lining of the stomach. There are many possible causes of this disorder including an infection, an irritant, an autoimmune disorder, or a backup of bile into the stomach. The stomach lining may be "eaten away," leading to sores (peptic ulcers) in the stomach or first part of the small intestine. Left untreated, these ulcers may bleed. Gastritis can occur suddenly (acute gastritis) or gradually (chronic gastritis). In most cases, gastritis does not permanently damage the stomach lining and sometimes no specific cause of the inflammation is identified.

Signs and Symptoms

The most common symptoms of gastritis are stomach upset and pain. The following are other symptoms of gastritis.

• Indigestion (also called dyspepsia)
• Heartburn
• Abdominal pain
• Hiccups
• Loss of appetite
• Nausea
• Vomiting, possibly of blood (called hematemesis) or material that looks like coffee-grounds
• Dark stools

Causes

Gastritis can be caused by infection, irritation, autoimmune disorders (disorders caused by the body's immune response against its own tissues), or backflow of bile into the stomach (bile reflux). Gastritis can also be caused by a blood disorder called pernicious anemia.

Infections can be any of the following types:

• Bacterial (usually Helicobacter pylori)
• Viral (including herpes simplex virus)
• Parasitic
• Fungal

Irritation can be caused by a number of things, such as the following:

• Long-term medication use (for example, aspirin, ibuprofen or other anti-inflammatory drugs [called NSAIDS])
• Alcohol use
• Cigarette smoking
• Chronic vomiting
• Coffee and acidic beverages
• Excess gastric acid secretion (such as from stress)
• Eating or drinking caustic or corrosive substances (such as poisons)
• Trauma (for example, radiation treatments or having swallowed a foreign object)

Other causes for gastritis are very rare. These include:

• Systemic disease (for example, Crohn's disease)
• Sarcoidosis

Risk Factors

• Infection with H. pylori
• Crowded, unsanitary conditions — this may increase risk of contracting H. pylori
• Acquired immunodeficiency syndrome (AIDS)
• Any condition that requires relief from persistent pain using NSAIDS, such as chronic low back pain, fibromyalgia, or arthritis
• Alcoholism
• Cigarette smoking
• Older age
• Genetic abnormalities

Diagnosis

There are several tests that may be done to make a diagnosis. These include endoscopy of the stomach, where a thin tube that has a light and a camera on the end is inserted down your throat to your stomach. This allows the doctor to see into your stomach and, if necessary, take samples (called a biopsy) from the lining. The laboratory tests you may need will depend on the specific cause of your gastritis. A stool test may be used to check for the presence of blood, or a biopsy may be taken of the tissues of your esophagus or stomach to determine the cause of your discomfort. A breath test may detect H. pylori, or samples from your esophagus or stomach may be taken to look for this organism.

Preventive Care

Making lifestyle changes, such as avoiding the long-term use of irritants (aspirin, anti-inflammatory drugs, coffee, and alcohol) will go a long way to preventing gastritis and its complications like an ulcer. Stress reduction through relaxation techniques including yoga, tai chi, and meditation can also be quite helpful.

Treatment Approach

The treatment of gastritis depends on the cause of the problem. Some causes may resolve by themselves over time, or may be relieved by stopping the ingestion of irritating substances such as alcohol, tobacco, and aspirin. Some dietary changes will no doubt be recommended, although the bland diet often prescribed in the past is no longer thought to be necessary. Medications are often necessary to relieve symptoms, eradicate an infection such as H. pylori, and prevent or treat complications from gastritis such as an ulcer.

Lifestyle

The cure for gastritis caused by ingesting irritating substances is to stop the long-term use of these substances, which may include:

• Alcohol
• Tobacco
• Acidic beverages such as coffee (both caffeinated and decaffeinated), carbonated beverages, and fruit juices with citric acid
• NSAIDS, such as aspirin and ibuprofen – switch to other pain relievers (like acetominophen)
• Eat a fiber-rich diet
• Avoid high fat foods (at least from animal studies, high fat foods incresase inflammation in the stomach lining)

Medications

Helicobactor pylori infestation, a common bacterial cause of gastritis and ulcers, is typically treated with a combination of drugs. The typical combination includes antibiotics, a bismuth compound, and a proton pump inhibitor. (Proton pump inhibitors reduce stomach acid secretion.) These drugs are usually taken for at least 14 days.

In addition to the medications used for Helicobacter pylori infection, other medications that may be used to relieve symptoms of gastritis include those that reduce stomach acid secretion:

• Antacids such as calcium carbonate and magnesium hydroxide with aluminum salts
• H2 blockers such as ranitidine, cimetidine, nizatidine, and famotidine
• Proton pump inhibitors such as omeprazole and lansoprazole

Drugs that reduce stomach acid secretion help protect against or treat ulcers. Other drugs used for ulcers include:

• Misoprostol – protects against the major intestinal toxicity of NSAIDS, and can reduce the formation of ulcers
• Sucralfate – helps to heal ulcers in the stomach

Nutrition and Dietary Supplements

Eating a diet high in fiber may not only cut your risk of developing ulcers in half, but fiber-rich foods may also speed the healing of ulcers. Fruits and vegetables are particularly protective sources of fiber and seem to reduce the amount of inflammation in the lining of the stomach; fruit juice appears to have this benefit as well. Plus, if you didn't have enough reasons to avoid fat in your diet already, animal studies suggest that high fat foods may lead to gastritis.

Consumption of foods and beverages that irritate the lining of the stomach or increase the stomach acids should be avoided completely or reduced, and known allergens eliminated. These often include:

• Alcohol
• Acidic drinks such as coffee (with and without caffeine)
• Milk
• Carbonated beverages
• Spices and peppers (for some people this is important, while for others such foods do not seem to cause symptoms or inflammation)

Gamma-linolenic acid (GLA)
Very preliminary evidence from test tube and animal studies suggest that gamma-linolenic acid (GLA) from evening primrose oil (EPO) may have anti-ulcer properties. GLA is an essential fatty acid (EFA) in the omega-6 family that is found primarily in plant-based oils, including EPO and borage seed oil. Although studies are promising, it is too early to know how this might apply to people with gastritis.

Probiotics
Healthy or "friendly" organisms, called probiotics, inhabit the lining of the intestines and protect us from the entrance of "bad" infections that can cause disease. Lactobacillus acidophilus (L. acidophilus) is the most commonly used probiotic. In test tube studies, L. acidophilus and other probiotics were able to kill or slow down the growth of H. pylori; research is needed to understand whether that benefit would occur in people. One way in which probiotics may help is by reducing side effects, such as diarrhea and taste disturbance, from medications used to treat H. pylori.

Vitamin B12
People with pernicious anemia and H. pylori infection are deficient in vitamin B12. Supplementation with this vitamin may be used to treat both. Good dietary sources of vitamin B12 include fish, dairy products, organ meats (particularly liver and kidney), eggs, beef, and pork.

Others
The following appear promising, but more research is needed before these nutrients become a part of treatment for gastritis, its symptoms, or its complications:

• Bromelain (Ananas comosus) — the protein-digesting enzymes found in bromelain (derived from pineapple) help promote and maintain proper digestion and may relieve symptoms of stomach upset or heartburn, particularly when used with other enzymes such as amylase (which digests starch) and lipase (which digests fat). Studies in people are needed.
• Vitamin A – found in many fruits and vegetables, is thought to increase the benefit of these foods (which are also rich in fiber as discussed earlier). One study suggests that the combination of vitamin A and antacids may be more effective than antacids alone in healing ulcers.
• Vitamin C — in one study, high-dose vitamin C treatment for four weeks effectively treated H. pylori infection in some, but not all, people. In addition, H. pylori appears to impair absorption of vitamin C, which may play a role in the higher risk of stomach cancer for those with this organism in their gastrointestinal tract.

Herbs

Herbs may cause side effects or interact with medications. They should, therefore, be used with caution and only under the guidance of a professionally trained and qualified herbalist. With that said, there are many herbs, some of which are described below, that may be recommended by an herbal specialist for symptoms of gastritis. The herbalist would work with you to individualize your treatment.

• Astragalus (Astragalus membranaceus) – used traditionally to treat stomach ulcers. May also prevent the damage from radiation or chemotherapy that can lead to gastritis.
• Barberry (Berberis vulgaris)- This herb contains active substances called berberine alkaloids. These substances have been shown to combat infection and bacteria. For this reason, barberry is used to ease inflammation and infection of the gastrointestinal tract. Barberry has also been used traditionally to improve appetite.
• Bilberry (Vaccinium myrtillus) - Studies in rats have found that anthocyanidins (an antioxidant) from bilberry fruits help prevent stomach ulcers caused by a variety of factors including stress, medications, and alcohol. Whether this will translate into help for people requires research.
• Cat's Claw (Uncaria tomentosa) – The bark and root of this herb have been used among indigenous people of the rainforest for centuries to treat a variety of health problems including ulcers and other gastrointestinal disorders. The benefits of this herb may be due to its ability to reduce inflammation.
• Chamomile, Roman (Chamaemelum nobile) - Traditionally, Roman chamomile has been used to treat nausea, vomiting, heartburn, and excess intestinal gas.
• Cranberry (Vaccinium spp.) – may have properties that help prevent H. pylori.
• Dandelion (Taraxacum officinale) - Native Americans have traditionally used dandelion to treat kidney disease, heartburn and stomach upset, amongst other conditions. Chinese medicinal practitioners traditionally used dandelion to treat digestive disorders, Today, dandelion roots are primarily used as an appetite stimulant and digestive aid. If you have gallbladder disease, you should not use dandelion.
• Devil's Claw (Harpagophytum procumbens) - many professional herbalists consider devil's claw to be useful for upset stomach and loss of appetite.
• Dong Quai (Angelica sinensis) - animal studies suggest that dong quai may soothe ulcers, but studies in people are needed before a definitive conclusion can be drawn.
• Ginger (Zingiber officinale) – In China, ginger has been used to aid digestion and treat stomach upset as well as nausea for more than 2,000 years. This herb is also thought to reduce inflammation.
• Green Tea (Camellia sinensis) – Population based studies conducted in Japan suggests that people who drink green tea regularly may be protecting themselves from developing chronic gastritis.
• Licorice (Glycyrrhiza glabra) - this herb is a demulcent (soothing, coating agent) that has long been valued for its use in food and medicinal remedies, including treatments for stomach ailments. Some licorice root extracts, known as deglycyrrhizinated licorice (DGL), still have the healing properties of licorice without the harmful effects (like high blood pressure). DGL may be better for stomach or duodenal ulcers and may even be as effective as some prescription drugs for stomach ulcers.
• Slippery elm (Ulmus fulva) - Although there has been little scientific research on slippery elm, it has a long history of use based on clinical experience. Gastritis and peptic ulcer are among the conditions that seem to respond to slippery elm.
• Turmeric (Curcuma longa) -Turmeric has long been used in both Ayurvedic and Chinese medicine to treat digestive disorders. Scientific research is beginning to test the merit of this traditional use. In an animal study, for example, extracts of turmeric root reduced the release of acid from the stomach and protected against injuries such as gastritis or inflammation of the intestinal walls and ulcers. Further studies are needed to know to what extent these protective effects apply to people as well. (Note: at very high doses, turmeric may induce ulcers. It is very important to stick with the dose recommended by an herbal specialist.)
• Yarrow (Achillea millefolium) – Used traditionally to reduce inflammation, increase appetite, and ease stomach upset.

Others
Animal studies show that certain individual herbal extracts as well as a combination of these extracts show promise in treating ulcers. The combination remedy also shows promise for treating dyspepsia (upper abdominal symptoms such as nausea, loss of appetite, and heartburn). In a study on 137 people with dyspepsia (indigestion), the combination preparation was as effective as the drug cisapride (a heartburn medication). More studies are needed before this combination becomes accepted treatment.

The combination preparation included the following extracts:

• Angelica (Angelica archangelica)
• German chamomile (Matricaria recutita)
• Lemon balm (Melissa officinalis)
• Licorice
• Milk thistle (Silybum marianum)
• Peppermint (Mentha x piperita)

Homeopathy

Although few studies have examined the effectiveness of specific homeopathic therapies, professional homeopaths may consider the following remedies for the treatment of gastritis symptoms (such as nausea and vomiting) based on their knowledge and experience. Before prescribing a remedy, homeopaths take into account your constitutional type. A constitutional type is defined as your physical, emotional, and psychological makeup. An experienced homeopath assesses all of these factors when determining the most appropriate treatment for you individually.

• Pulsatilla — for heartburn, queasiness, a bad taste in the mouth brought on by eating rich foods and fats (especially ice cream); symptoms may include vomiting partly digested food; this remedy is most appropriate for an individual whose tongue is coated with a white or yellow substance
• Ipecacuahna — for persistent and severe nausea, with or without vomiting and diarrhea, caused by an excess of rich or fatty foods
• Carbo vegetabilis — for bloating and indigestion, especially with flatulence and fatigue
• Nux vomica — for heartburn, nausea, retching without vomiting, and sour burps caused by overeating, alcohol use, or coffee drinking; this remedy is most appropriate for individuals who also feel irritable and sensitive to noise and light

Other Considerations

Return to your healthcare provider if your symptoms do not get better or if they get worse. Do not ignore potentially life-threatening symptoms such as vomiting blood or blood in your stool. Be aware that you may not see frank blood in your stool; it may simply look very dark, even black. Be sure to see your healthcare provider regularly, and call him or her if there is any change in your symptoms.

If you are on both antibiotics and vitamin B12, take them at different times of day because vitamin B12 interferes with antibiotic absorption.

Pregnancy
If you are pregnant or breastfeeding, you should consult with your physician before taking any medication, including herbs.

Borage seed oil, and possibly other sources of GLA, should not be used during pregnancy because they may be harmful to the fetus and induce early labor.

Prognosis and Complications

Symptoms of H. pylori infection are usually relieved with treatment, but you will most likely be asked to see your doctor four weeks or more after stopping your drug regimen. Follow-up is very important, because the H. pylori bacteria is linked to stomach cancer.

Peptic ulcers may develop when digestive juices damage the lining of the stomach or the first part of the small intestine (called the duodenum). These ulcers can generally be treated effectively with lifestyle changes and medication.

References

al-Shabanah OA. Effect of evening primrose oil on gastric ulceration and secretion induced by various ulcerogenic and necrotizing agents in rats. Food Chem Toxicol. 1997;35(8):769-775.

Berberine. Altern Med Rev. 2000;5(2):175-177.

Blumenthal M, Goldberg A, Brinckmann J. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000:379-384.

Bujanda L. The effects of alcohol consumption upon the gastrointestinal tract. Am J Gastroenterol. 2000;95(12):3374-3382.

Clopidogrel. NMIHI. Accessed at http://www.nmihi.com/c/clopidogrel.html on July 4, 2018.

Burger O, Ofek I, Tabak M, Weiss EI, Sharon N, Neeman I. A high molecular mass constituent of cranberry juice inhibits helicobacter pylori adhesion to human gastric mucus. FEMS Immunol Med Microbiol. 2000 Dec;29(4):295-301.

Burger O, Weiss E, Sharon N, Tabak M, Neeman I, Ofek I. Inhibition of Helicobacter pylori adhesion to human gastric mucus by a high-molecular-weight constituent of cranberry juice. Crit Rev Food Sci Nutr. 2002;42(3 Suppl):279-284.

Carr AC, Frei B. Toward a new recommended dietary allowance for vitamin C based on antioxidant and health effects in humans. Am J Clin Nutr. 1999;69(6):1086-1107.

Co-amoxiclav. NMIHI. Accessed at http://www.nmihi.com/c/co-amoxiclav.html on July 4, 2018.

Cremonini F, Di Caro S, Covino M, et al. Effect of different probiotic preparations on anti-helicobacter pylori therapy-related side effects: a parallel group, triple blind, placebo-controlled study. Am J Gastroenterol. 2002;97(11):2744-2749.

Esomeprazole. NMIHI. Accessed at http://www.nmihi.com/e/esomeprazole.html on July 4, 2018.

Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998: 941-943,1610-1614.

Gastric ulcers. NMIHI. Accessed at http://www.nmihi.com/u/ucler.htm on April 13, 2018.

Gastritis. NIH. Accessed at https://www.niddk.nih.gov/ on July 4, 2018.

Gastritis. MedlinePlus. Accessed at https://medlineplus.gov/ on July 4, 2018.

Gorbach SL. Probiotics in the third millennium. Dig Liver Dis. 2002;34(Suppl 2):S2-S7.

Jarosz M. Effects of high dose vitamin C treatment on Helicobacter pylori infection and total vitamin C concentration in gastric juice. Eur J Cancer Prev. 1999;7(60:449-454.

Kaptan K, Beyan C, Ural AU, et al. Helicobacter pylori – is it a novel causative agent in vitamin B12 deficiency? Arch Intern Med. 2000;160(9):1349-1353.

Khayyal MT, el-Ghazaly MA, Kenawy SA, et al. Antiulcerogenic effect of some gastrointestinally acting plant extracts and their combination. Arzneimittelforschung. 2001;51(7):545-553.

Laurila A, Cole SP, Merat S, et al. High-fat, high-cholesterol diet increases the incidence of gastritis in LDL receptor-negative mice. Atherioscler Thromb Vasc Biol. 2001;21(6):991-996.

Lederle FA. Oral cobalamin for pernicious anemia. Medicine's best kept secret? JAMA. 1991;265:94-95.

Levine M, Rumsey SC, Daruwala R, Park JB, Wang Y. Criteria and recommendations for vitamin C intake. JAMA. 1999;281(15):1415-1453.

Magistretti NJ, Conti M, Cristini A. Antiulcer activity of an anthocyanidin from Vaccinium myrtillus. Arzneim-Forsch. 1988;38:686–690.

Mahmood T, Tenenbaum S, Niu XT, Levenson SM, Seifter E, Demetriou AA. Prevention of duodenal ulcer formation in the rat by dietary vitamin A supplementation. J Parenter Enteral Nutr. 1986;10(1):74-77.

Marteau PR. Probiotics in clinical conditions. Clin Rev Allergy Immunol. 2002;22(3):255-273.

Marteau P, Boutron-Ruault MC. Nutritional advantages of probiotics and prebiotics. Br J Nutr. 2002;87(Suppl 2)):S153-S157.

Michetti P, Dorta G, Wiesel PH, et al. Effect of whey-based culture supernatant of Lactobacillus acidophilus (johnsonii) La1 on Helicobacter pylori infection in humans. Digestion. 1999;60(3):203-209.

Misoprostol. NMIHI. Accessed at http://www.nmihi.com/m/misoprostol.html on July 4, 2018.

Patty I, Benedek S, Deak G, et al. Cytoprotective effect of vitamin A and its clinical importance in the treatment of patients with chronic gastric ulcer. Int J Tissue React. 1983;5:301-307.

Qasim A, O'Morain CA. Review article: treatment of Helicobacter pylori infection and factors influencing eradication. Aliment Pharmacol Ther. 2002;16(Suppl 1):24-30.

Rosch W, Vinson B, Sassin I. A randomised clinical trial comparing the efficacy of a herbal preparation STW 5 with the prokinetic drug cisapride in patients with dysmotility type of functional dyspepsia. Z Gastroenterol. 2002;40(6):401-408.

Shibata K, Mariyama M, Fukushima T, Kaetsu A, Miyazaki M, Une H. Green tea consumption and chronic atrophic gastritis: a cross-sectional study in a green tea production village. J Epidemiol. 2000;10(5):310-316.

What causes gastritis? Cleveland Clinic. Accessed at https://my.clevelandclinic.org/ on July 4, 2018.

Woodward M, Tunstall-Pedo H, McColl K. Helicobacter pylori infection reduces systemic availability of dietary vitamin C. Eur J Gastroenterol Hepatol. 2001;13(3):233-237.