What is Stress-Induced Gastritis?
Gastric acid, or stomach acid, is crucial for our bodies to digest food and break down nutrients into forms our bodies can use, such as proteins, carbs, and fats. This stomach acid is mainly produced when the stomach’s acidity level triggers the release of various enzymes that aid digestion. The stomach is quite an acidic place, with a pH lower than 4.0, and this acidity can increase to 2.0 with the help of cells known as parietal cells. These cells are located in the fundus and the body of the stomach and their job is to secrete hydrogen ions. In other words, they produce acid. There are three main substances that stimulate parietal cells to do this job.
One of these substances is a neurotransmitter known as acetylcholine (ACH). ACH prompts parietal cells to secrete hydrogen through a process involving phospholipase, an enzyme found on the cell wall. This enzyme is stimulated indirectly by ACH, leading to the creation and release of calcium ions into the cell contents or cytoplasm. These ions bind with a protein called calmodulin and activate another protein called protein kinase C (PKC). PKC triggers the activation of an enzyme that stimulates the secretion of acid. ACH is transmitted from the vagus nerve, which is the tenth cranial nerve in the body.
The second substance is gastrin, a hormone also known to encourage hydrogen ion secretion following the same process as ACH, resulting in the activation of the stomach acid secreting function. Gastrin is mainly produced by cells known as G cells, which are found in the antrum of the stomach and are stimulated by the presence of proteins and ACH.
The third substance, histamine, triggers parietal cells to secrete hydrogen ions through a different process where it activates protein kinase A and subsequently the acid secreting function. Histamine is usually produced by cells called mast cells, which surround the stomach tissues.
If these mechanisms go awry, it can result in conditions such as stress gastritis, sometimes known as hemorrhagic or erosive gastropathy, where the protective layer of your stomach is damaged due to severe or acute illness. The aim of this article is to talk about the causes and ways to prevent and identify stress gastritis.
What Causes Stress-Induced Gastritis?
Changes in the normal acidity level of your stomach can disrupt the usual process of digestion. This can happen due to physical stress on the body, leading to inflamed stomach lining or stress-induced gastritis. During periods of stress, your body may produce more acid in the stomach which can cause this inflammation.
Typically, patients who experience this are found in the surgical area of a hospital or in the intensive care unit. These patients are usually critically ill, having experienced severe physical stress due to things like major injury, extensive burns, being dependent on a ventilator, or trauma to the brain.
If physical stress leads to gastritis, it can cause small sores in the stomach lining, known as curling ulcers. If these sores are due to a problem originating in the brain, they’re named Cushing ulcers, after the famous neurosurgeon Harvey Cushing.
The first step towards stress-induced gastritis is a decrease in the resistance of the stomach lining to harmful substances. Stress can lead to a decrease in the renewal of stomach lining cells, resulting in thinning of the stomach lining. A decrease in blood flow to the stomach can make it more susceptible to sores caused by acidic digestive juices and an increased secretion of digestive acid.
Risk Factors and Frequency for Stress-Induced Gastritis
In 2002, around 81 out of every 100,000 people experienced upper gastrointestinal bleeding. However, by 2012, this rate dropped to 67 out of 100,000. The biggest decrease was seen in those with stomach inflammation (gastritis) and ulcers (peptic ulcer disease). This decrease, by 55% for gastritis and 30% for ulcers, was likely due to the early use of medications known as proton pump inhibitors or histamine blockers. Even so, many critically ill patients who aren’t taking these preventative drugs still develop asymptomatic gastritis, where they don’t show symptoms, with estimates above 75%.
- Among those who develop a stress gastric ulcer, the incidence rate of hidden (or “occult”) bleeding is 15-50%.
- Overt bleeding, meaning noticeable or obvious bleeding, happens in 1.5-8.5% of these cases.
- Stress gastric ulcers with significant bleeding are much less common, happening only in 1-3% of cases.
Signs and Symptoms of Stress-Induced Gastritis
Stress-induced gastritis usually occurs after a person experiences a highly stressful event. This could be the result of severe physical trauma from events like a major car accident or falling and breaking multiple bones. Other events, such as a serious illness like pneumonia or heart attack, or major surgery, can cause stress gastritis. Even severe untreated psychological stress, like depression, can lead to this condition.
The condition of the patient can vary greatly, depending on what caused the stress gastritis. If the patient has undergone major surgery, their vital signs might be stable, but they’re still dealing with a large amount of stress on their body. A patient who had a severe heart attack might have more unstable vitals. And someone with traumatic injuries could have extremely unstable vitals until they receive proper medical treatment.
People with stress gastritis often exhibit the following symptoms:
- Vomiting material that looks like coffee grounds
- Vomiting blood
- Black, tarry stools
- Abdominal pain
- Nausea
- Dizziness when standing up quickly, in more severe cases
Testing for Stress-Induced Gastritis
If a tube is inserted into your nose and down into your stomach after cleansing with a saline solution, the substance that comes out might have a bloody appearance. This procedure can often assure the doctor that you’re not having a severe stomach bleed if the liquid that returns after the tube insertion appears greenish and similar to bile. A test to detect hidden blood in your stool (fecal occult blood test or FOBT) is also carried out.
An endoscopy, a procedure where a small camera is inserted into your digestive tract, is used to pinpoint the cause of the issue. If you’re suffering from stress-induced inflammation in your stomach lining (stress gastritis), the doctor could see small shallow sores or red patches in the main part and upper area of your stomach during this procedure.
In addition, the doctor might perform tests to check for a bacteria called H. pylori, which can cause stomach inflammation and ulcers. These tests could include a breath test or a test which checks for the bacteria’s presence in your stool.
Treatment Options for Stress-Induced Gastritis
Thanks to advances in intensive care, the occurrence of stress-induced gastritis (a type of stomach inflammation) has declined. The primary treatment method involves using a type of drug known as Proton Pump Inhibitors (PPIs), and if required, histamine blockers are used as a secondary line of treatment.
PPIs, including medications like omeprazole and lansoprazole, operate by permanently blocking an enzyme known as H/K ATPase. This enzyme is responsible for the secretion of hydrogen ions, a crucial part of stomach acid production. By inhibiting this enzyme, PPIs can reduce the production of stomach acid, regardless of levels of other substances like acetylcholine and gastrin. However, it’s important to note that when a patient stops using a PPI, they may experience a temporary spike in acid production. This is due to a backup of gastrin, a hormone that usually aids in the production of stomach acid.
Histamine blockers, like famotidine, work differently. They don’t directly influence the H/K ATPase of stomach cells. Instead, they prevent the stimulation of these cells by histamine, a chemical that normally increases the activity of the H/K ATPase, leading to a decrease in stomach acid production.
Since stress-induced gastritis can be severe in critically ill patients, it’s crucial to start treatment with PPIs and histamine blockers early to protect the stomach lining. Research is ongoing to understand how to lessen the negative effects of angiotensin, a hormone that can increase stomach acid production under stress, on the stomach lining.
What else can Stress-Induced Gastritis be?
When diagnosing certain conditions, doctors should also consider these potential causes that might show similar symptoms:
- Stomach ulcers
- Gastritis caused by nonsteroidal anti-inflammatory drugs (NSAIDs)
- Stomach issues related to alcohol consumption
- Gastroesophageal reflux disease (GERD) – a condition that causes acid reflux
- Cancer in the stomach or esophagus
- Gastroparesis – a condition that slows or stops the movement of food from the stomach to the small intestine
- Pancreatic cancer
- Biliary pain – discomfort related to the gallbladder or bile ducts
- Uremic gastropathy – stomach complications due to kidney disease
- Dyspepsia – long-term or recurrent pain in the upper abdomen
What to expect with Stress-Induced Gastritis
The outcome of the patient typically depends on how severe the triggering incident is. If the patient is otherwise in a stable condition but is not given preventative treatment with proton pump inhibitors (PPI) or histamine blockers, there is a risk of them experiencing a potentially fatal bleeding in the intestines. This can then lead to a tear in the wall of the intestines, a condition known as perforation, followed by septic shock, a serious infection spreading throughout the body, and possibly death.
However, if preventative measures are taken for patients who are at risk of developing stress ulceraTion, the outcome usually remains positive in most situations. Stress ulceration is a condition where ulcers, or sores, form in the stomach because of severe illness or stress.
Possible Complications When Diagnosed with Stress-Induced Gastritis
Stress ulcers can lead to a series of complications.
- Bleeding
- Anemia, a condition when you lack enough healthy red blood cells
- Strictures, narrowing of the esophagus
- Perforation, or the making of a hole
- Peritonitis, inflammation of the tissue inside the abdomen
- Gastrocolic fistula due to ulcer perforation, which is an abnormal connection between the stomach and colon
- Gastric outlet obstruction due to strictures, which is a blockage preventing stomach contents from passing into the small intestine
- Hemorrhagic shock, a severe drop in blood pressure caused by a significant loss of blood
- Increase in ICU stay
- In severe cases, it may even lead to death
Preventing Stress-Induced Gastritis
Stress gastritis is a condition where the digestive tract develops sores that can lead to discomfort in the stomach and, in some cases, bleeding. Telltale signs of stress gastritis include pain in the upper part of the stomach, feeling nauseous, vomiting, or finding blood in your stool. This happens mainly when you are stressed, as your body produces more acid than normal. Also during such times, the protective mucus layer on the lining of your digestive tract is weakened, leaving it more prone to damage.
A preventive treatment given in intensive care units can help reduce the chances of these stress ulcers coming back. Medical professionals are your best guide for concerns regarding ulcers caused by stress. Therefore, it is important to seek their advice if you come across any symptoms or have concerns related to stress gastritis.
