Alcoholic Gastritis

Acute or chronic gastric mucosal inflammation and erosion caused by alcohol, through direct toxic injury, disruption of the mucus barrier, increased acid secretion, ischaemia, and reduced prostaglandin protection.

• Acute binge drinking causes erosive and haemorrhagic gastritis within hours; chronic use causes chronic gastritis with atrophy, and increases the effects of H. pylori and NSAIDs.
• Alcohol related gastric injury accounts for about 10 to 15% of upper gastrointestinal bleeding in drinkers; erosions are seen at endoscopy in up to 30 to 40% of heavy drinkers; it often coexists with Mallory-Weiss tears, oesophagitis, portal hypertensive gastropathy and varices.
• Spirits and high concentration drinks (more than 15% alcohol) are more injurious than beer or wine.

Epigastric pain, nausea, vomiting (after a binge), loss of appetite, retching, haematemesis (fresh blood or coffee grounds), melaena.

• Signs of chronic alcohol use: tremor, spider naevi, palmar erythema, hepatomegaly, parotid enlargement, malnutrition.
• Withdrawal features within 6 to 48 hours of stopping: tremor, sweating, agitation, hallucinations, seizures.
• Differential diagnosis: Mallory-Weiss tear, oesophageal or gastric varices, peptic ulcer, alcoholic pancreatitis, alcoholic hepatitis, Boerhaave syndrome (severe pain after vomiting), mesenteric ischaemia, myocardial infarction, gastric cancer.
• Complications: haemorrhage, iron deficiency anaemia, folate and B12 deficiency, malnutrition, Wernicke encephalopathy, progression to chronic atrophic gastritis, and gastric cancer risk (raised in heavy drinkers).

History: quantity, pattern and duration of drinking; screening questionnaire; previous withdrawal, seizures and delirium; other drugs (NSAIDs, aspirin).

• Endoscopy for bleeding or persistent symptoms: erythema, erosions, petechiae, blood in the stomach; check for varices, ulcer, Mallory-Weiss tear, and portal hypertensive gastropathy (snake-skin mucosa); biopsies for H. pylori and histology.
• Blood tests: full blood count (macrocytosis, anaemia, low platelets), liver tests (gamma glutamyl transferase, aspartate aminotransferase higher than alanine aminotransferase), INR, albumin, urea and creatinine, electrolytes, magnesium, phosphate, glucose, lipase, ferritin, B12 and folate, blood alcohol level.
• Ultrasound of the liver for cirrhosis and portal hypertension; H. pylori test.

Stop alcohol; manage withdrawal and prevent Wernicke encephalopathy before giving glucose:

• Thiamine 200 to 300 mg IV three times daily for 3 to 5 days (for example 2 pairs of high-potency B vitamin ampoules three times daily), then thiamine 100 mg orally three times daily; for suspected Wernicke encephalopathy give 500 mg IV three times daily for 2 to 3 days.
• Folic acid 5 mg daily, magnesium sulfate 2 g IV over 20 minutes if low, potassium and phosphate replacement.
• Chlordiazepoxide 20 to 30 mg orally four times daily on day 1, reducing by 20% each day over 5 to 7 days (lorazepam 1 to 2 mg every 4 to 6 hours in liver disease or the elderly); for seizures lorazepam 4 mg IV, repeated once after 10 minutes if needed.

```{=html} <!-- --> ``` - Acid suppression and mucosal healing: omeprazole 40 mg daily for 4 to 8 weeks; alginate-antacid 10 to 20 mL after meals and at bedtime; sucralfate 1 g four times daily for 4 weeks (evidence limited).

• Bleeding: resuscitation, omeprazole 80 mg IV bolus then 8 mg/hour for 72 hours, transfuse at 70 g/L (80 g/L in cardiovascular disease), correct coagulopathy (vitamin K 10 mg IV daily for 3 days, platelets to 50 x 10^9/L or more), endoscopy within 24 hours; in suspected variceal bleeding add terlipressin 2 mg IV every 4 to 6 hours for 2 to 5 days and ceftriaxone 1 g IV daily for 5 to 7 days.
• Antiemetics: ondansetron 4 to 8 mg IV or orally every 8 hours; metoclopramide 10 mg three times daily for no more than 5 days; avoid sedating antiemetics in encephalopathy.
• Helicobacter pylori eradication when positive for 14 days: omeprazole 20 mg twice daily, amoxicillin 1 g twice daily and clarithromycin 500 mg twice daily, or omeprazole 20 mg twice daily, bismuth subsalicylate 524 mg four times daily, tetracycline 500 mg four times daily and metronidazole 500 mg three to four times daily (avoid metronidazole with disulfiram).
• Nutrition: oral diet when tolerated, high-protein diet (1.2 to 1.5 g/kg/day) and late evening snack in cirrhosis; refeeding precautions with thiamine first and electrolyte checks daily for 3 days.
• Relapse prevention: brief intervention before discharge, referral to addiction services, and drugs when abstinent: naltrexone 50 mg daily (avoid with opioids and in acute hepatitis), or acamprosate 666 mg three times daily (333 mg three times daily if creatinine clearance is 30 to 50 mL/min; avoid below 30 mL/min), or baclofen 5 to 10 mg three times daily in liver disease (evidence limited); avoid disulfiram in liver disease.
• Special groups: pregnancy (stop alcohol, thiamine and folic acid 5 mg, omeprazole 20 mg daily, avoid misoprostol and bismuth); elderly (lower doses of sedatives, falls prevention, check for delirium); hepatic impairment (use lorazepam, limit paracetamol to 2 g daily, screen for varices); renal impairment (adjust acamprosate and famotidine); young drinkers (screen for binge drinking and dependence).
• Red flags: haematemesis, melaena, seizures, delirium tremens, confusion or ataxia, jaundice or ascites, severe pain after vomiting (perforation), unexplained weight loss.
• Follow-up: review at 2 to 4 weeks; liver tests, B12, folate and full blood count at 4 to 8 weeks; repeat endoscopy for gastric ulcer or unresolved bleeding; test of cure for H. pylori; addiction service review and screening for liver fibrosis annually.