Gastritis / Esophagitis

Inflammatory mucosal injury of the stomach or esophagus

Symptoms / Associated Sx

  • Epigastric burning, nausea, vomiting (gastritis)

  • Heartburn, regurgitation, chest pain, odynophagia (esophagitis)

  • Dysphagia if severe erosive esophagitis or stricture

  • Hematemesis or coffee-ground emesis if erosive/hemorrhagic

Denies

  • Melena or hematochezia (rules out significant active GI bleed if absent)

  • Weight loss (rules out malignancy)

  • Fever with odynophagia (rules out infectious esophagitis if absent)

  • Dysphagia (rules out esophageal cancer or stricture if truly absent)

Social History (SHx)

NSAID/alcohol/tobacco (gastritis); obesity, hiatal hernia, recumbency after meals (GERD/esophagitis); immunosuppression (infectious esophagitis); medications without water (pill esophagitis).

Main Etiology

  • Gastritis: H. pylori, NSAIDs, alcohol, bile reflux, autoimmune, stress

  • Erosive esophagitis: GERD (most common), ZE syndrome, hiatal hernia

  • Infectious esophagitis: Candida (immunocompromised), HSV, CMV

  • Pill esophagitis: bisphosphonates, doxycycline, KCl, NSAIDs

  • EoE: allergic/immune-mediated

Most Common DDx

  • PUD (discrete ulcer on EGD vs. diffuse mucosal inflammation; H. pylori positive more specific to PUD)

  • GERD without esophagitis (symptoms identical but EGD normal; diagnosed clinically or by pH monitoring)

  • Cardiac chest pain (esophagitis and ACS both cause chest pain; EKG, troponin, and response to PPI help differentiate)

  • Esophageal motility disorder / achalasia (dysphagia + chest pain; manometry distinguishes; normal EGD)

  • EoE (young male, atopy, food impaction history; biopsy ≥15 eos/hpf distinguishes from GERD esophagitis)

  • Infectious esophagitis (odynophagia dominant + immunocompromised; white plaques on EGD = Candida; vesicles = HSV)

  • Functional dyspepsia (normal EGD; no H. pylori; no structural cause)

DATA

  • CBC (anemia if hemorrhagic gastritis)

  • H. pylori stool antigen or urea breath test

  • EGD — definitive; biopsy for H. pylori, eosinophils (EoE), culture (infectious)

  • CMV/HSV PCR or serology if immunocompromised

Home Meds

  • NSAIDs, aspirin, corticosteroids (hold)

  • Bisphosphonates (pill esophagitis — hold, reassess route)

  • Immunosuppressants (infectious esophagitis risk)

  • Existing PPI/H2 blocker (escalate if insufficient)

Plan

  • Gastritis: Pantoprazole 40 mg PO BID × 4–8 weeks; H. pylori treatment if positive; avoid NSAIDs/alcohol

  • Erosive esophagitis/GERD: Pantoprazole 40 mg PO BID × 8 weeks (LA grade C/D); step-down to daily PPI; lifestyle modification; Famotidine 20 mg PO BID if PPI intolerant

  • Candida esophagitis: Fluconazole 200 mg PO/IV loading → 100–200 mg daily × 14–21 days

  • HSV esophagitis: Acyclovir 400 mg PO 5× daily × 14–21 days (IV if unable to take PO)

  • CMV esophagitis: Ganciclovir 5 mg/kg IV q12h × 21 days → valganciclovir step-down

  • EoE: Budesonide oral suspension 2 mg PO BID × 12 weeks OR swallowed fluticasone; 6-food elimination diet; GI dietitian referral

  • Trend CBC, BMP daily if admitted for hemorrhagic gastritis; PT/OT if prolonged admission

  • Discharge: PPI 4–8 weeks; GERD lifestyle counseling; follow-up EGD 8 weeks for severe erosive esophagitis; GI referral for EoE, refractory GERD, Barrett's concern

Red Flags

  • Hematemesis + hemodynamic instability → hemorrhagic gastritis → IV PPI + urgent EGD

  • Severe odynophagia + immunocompromised → infectious esophagitis → empiric antifungal + EGD

  • Dysphagia + weight loss → malignancy → urgent EGD with biopsy

  • Refractory esophagitis despite PPI → ZE syndrome, EoE, or achlorhydria masking

Senior IM Resident Pearls

  • Los Angeles classification: Grade A (≤1 break ≤5 mm) → Grade D (≥2 breaks >75% circumference) — grade C/D needs BID PPI × 8 weeks

  • EoE diagnosis: ≥15 eos/hpf on biopsy; classic in young males with atopy; treated with swallowed topical steroids or 6-food elimination

  • Autoimmune gastritis: Anti-parietal cell + anti-intrinsic factor Abs; B12 deficiency; monitor for gastric NET and adenocarcinoma

  • Common mistake: Treating esophagitis empirically as GERD in immunocompromised — always consider infectious etiology and scope early

ORDERS

Labs

Admission Labs

  • CBC with diff (anemia, infection)

  • BMP (electrolytes, renal function)

  • CMP if liver disease suspected

  • H. pylori stool antigen or urea breath test

  • PT/INR if bleeding or anticoagulated

Additional Labs

  • Iron studies if chronic blood loss

  • Vitamin B12 level (autoimmune gastritis)

  • Anti-parietal cell antibodies

  • Anti-intrinsic factor antibodies

  • CMV PCR (immunocompromised)

  • HSV PCR (immunocompromised)

  • HIV test if infectious esophagitis suspected

  • Eosinophil count (possible EoE)

Trending Labs

  • CBC daily if hemorrhagic gastritis

  • BMP daily if admitted

  • Hgb/Hct q6–8 hr if active bleeding

Imaging

Usually Not Needed

If Alternative Diagnosis Suspected

  • CXR (chest pain evaluation)

  • EKG + Troponin (ACS rule out)

  • CT Chest if concern for perforation, malignancy, severe dysphagia

Procedures

Diagnostic

  • EGD with biopsy

During EGD

  • H. pylori biopsy

  • Esophageal biopsy for EoE

  • Biopsy/culture for HSV/CMV

  • Evaluate severity of erosive esophagitis (LA Grade A-D)

If Severe Bleeding

  • Two large-bore IVs

  • Telemetry

  • NPO

  • Urgent EGD

Medications

Gastritis

First Line

  • Pantoprazole 40 mg PO BID x4–8 weeks

If Unable to Take PO

  • Pantoprazole 40 mg IV BID

Active Hemorrhagic Gastritis

  • Pantoprazole 80 mg IV bolus

  • Then 8 mg/hr infusion x72 hr

GERD / Erosive Esophagitis

Mild–Moderate

  • Pantoprazole 40 mg PO daily

Severe (LA Grade C/D)

  • Pantoprazole 40 mg PO BID x8 weeks

Step-Down

  • Pantoprazole 40 mg PO daily

PPI Intolerance

  • Famotidine 20 mg PO BID

H. pylori Positive

Bismuth Quadruple Therapy x14 days

  • Pantoprazole 40 mg PO BID

  • Bismuth subsalicylate 525 mg PO QID

  • Tetracycline 500 mg PO QID

  • Metronidazole 250–500 mg PO QID

Candida Esophagitis

Mild–Moderate

  • Fluconazole 200 mg PO/IV x1

  • Then 100–200 mg PO daily x14–21 days

Severe

  • Fluconazole 400 mg PO/IV daily

HSV Esophagitis

  • Acyclovir 400 mg PO 5x/day x14–21 days

Severe

  • Acyclovir 5 mg/kg IV q8h

CMV Esophagitis

  • Ganciclovir 5 mg/kg IV q12h x21 days

Step-Down

  • Valganciclovir 900 mg PO BID

Eosinophilic Esophagitis (EoE)

Option 1

  • Budesonide oral suspension 2 mg PO BID x12 weeks

Option 2

  • Swallowed fluticasone 440–880 mcg BID

Dietary

  • Six-food elimination diet

Hold Medications

  • NSAIDs

  • Aspirin (if possible)

  • Steroids if contributing

  • Bisphosphonates

  • Doxycycline

  • Potassium chloride tablets

  • Other offending pill-esophagitis medications

Consults

Gastroenterology

  • EGD

  • Refractory GERD

  • Dysphagia

  • GI bleeding

  • Suspected EoE

Infectious Disease

  • Severe CMV esophagitis

  • Severe HSV esophagitis

  • Immunocompromised patients

Dietitian

  • EoE

  • GERD lifestyle counseling

PT/OT

  • Deconditioning

  • Prolonged hospitalization

Nursing Orders

Monitoring

  • Vital signs q4 hr

  • Monitor hematemesis

  • Monitor dysphagia/odynophagia

  • Strict I&O if poor PO intake

Diet

  • GERD diet

  • Avoid alcohol

  • Avoid caffeine

  • Avoid late meals

  • Elevate HOB >30°

  • Remain upright 30–60 min after meals

If EGD Planned

  • NPO after midnight

Follow-Up Studies

  • Follow H. pylori testing

  • Follow biopsy pathology

  • Follow HSV/CMV studies

  • Follow eosinophil counts/biopsy results

  • Repeat EGD in 8 weeks if severe erosive esophagitis

  • Repeat EGD if Barrett's esophagus concern