Gastritis surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahad Hasan, M.D.[2] Aravind Reddy Kothagadi M.B.B.S[3]

Overview

Surgery is reserved for rare, life-threatening complications of gastritis that have failed or are not amenable to medical management. The principal surgical indications are: (1) phlegmonous gastritis with refractory sepsis, gastric gangrene, or perforation; (2) emphysematous gastritis with gastric ischemia or necrosis confirmed on imaging or endoscopy; (3) symptomatic postgastrectomy bile reflux gastritis refractory to maximal medical therapy; and (4) upper gastrointestinal hemorrhage from stress-related mucosal disease that is not controlled by endoscopic or interventional radiologic means. Understanding the specific surgical indications, procedural options, and postoperative considerations is essential for optimal patient outcomes in these uncommon but critically ill presentations.

Differential Diagnosis

The following conditions should be considered when evaluating a patient with suspected complicated gastritis presenting with acute abdomen or upper gastrointestinal emergency requiring surgical assessment:

Disease	Key Distinguishing Features	Relevant Diagnostic Studies
Peptic ulcer disease with perforation	Sudden onset epigastric pain, free air under diaphragm on chest X-ray, peritonitis	CT abdomen, upper GI series, esophagogastroduodenoscopy (after perforation excluded)
Gastric cancer	Insidious onset, weight loss, early satiety; irregular mucosal mass on CT or endoscopy; biopsy confirms malignancy	Esophagogastroduodenoscopy with biopsy, CT chest/abdomen/pelvis
Boerhaave syndrome	Violent retching preceding chest/epigastric pain; pneumomediastinum; pleural effusion	CT thorax, upper GI series with water-soluble contrast
Acute pancreatitis	Radiating pain to back, elevated amylase/lipase; peripancreatic inflammation on CT	CT abdomen, serum lipase, abdominal ultrasound
Mesenteric ischemia	Severe abdominal pain out of proportion to examination, risk factors for vascular disease, lactic acidosis	CT angiography of abdomen/pelvis, LDH, lactate
Gastric volvulus	Borchardt's triad (epigastric pain, unproductive retching, inability to pass nasogastric tube); dilated stomach on X-ray	CT abdomen, upper GI series
Gastric lymphoma	Lymphadenopathy, B symptoms; diffuse gastric wall thickening; biopsy shows lymphoid infiltrate	Esophagogastroduodenoscopy with biopsy, CT, endoscopic ultrasound
Crohn's disease of the stomach	Transmural inflammation; skip lesions; granulomas on biopsy; concurrent ileocolonic involvement	Esophagogastroduodenoscopy with biopsy, CT enterography, ileocolonoscopy
Ischemic gastropathy	Mucosal ischemia pattern; underlying vascular disease or systemic hypoperfusion	CT angiography, esophagogastroduodenoscopy

Surgery

Indications for Surgical Intervention

Surgery is not a routine component of gastritis management. The decision to proceed with surgery requires a thorough assessment of the underlying etiology, disease severity, response to non-operative measures, and patient comorbidities. Recognized surgical indications include the following:

Indication	Trigger for Surgery	Preferred Procedure
Phlegmonous gastritis	Failure of intravenous antibiotics; gastric gangrene; perforation; refractory septic shock	Partial or total gastrectomy; drainage of abscess; esophagojejunostomy if total gastrectomy performed
Emphysematous gastritis	Confirmed gastric ischemia on esophagogastroduodenoscopy or computed tomography; failure of conservative management; hemodynamic instability	Exploratory laparoscopy/laparotomy; partial or total gastrectomy based on extent of necrosis
Bile reflux gastritis (postgastrectomy)	Refractory symptoms despite maximal medical therapy; confirmed bile reflux on endoscopy and scintigraphy	Roux-en-Y gastrojejunostomy diversion
Stress-related mucosal disease hemorrhage	Endoscopic and interventional radiologic failure to control upper gastrointestinal bleeding	Vagotomy and pyloroplasty; partial or near-total gastrectomy in refractory cases
Gastric necrosis / gastric volvulus with ischemia	Acute transmural ischemia or gangrene	Gastric resection; extent determined intraoperatively

Initial Management

Before proceeding to operative intervention, initial resuscitative measures are mandatory. Patients with complicated gastritis requiring surgical consideration should receive:

• Hemodynamic stabilization: Intravenous fluid resuscitation, correction of coagulopathy, and vasopressor support as needed in the setting of septic shock.
• Nil per os (NPO) status and nasogastric tube insertion for gastric decompression.
• Broad-spectrum intravenous antibiotics: Empiric coverage including gram-positive, gram-negative, and anaerobic organisms (e.g., piperacillin/tazobactam or meropenem); antifungal coverage (e.g., fluconazole) should be added when fungal superinfection is suspected.
• Urgent computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast as the diagnostic modality of choice to delineate the extent of gastric wall involvement, intramural gas, free air, abscess, and vascular compromise.
• Urgent esophagogastroduodenoscopy (EGD): May be performed after CT to assess mucosal ischemia and guide decisions regarding extent of resection, provided the patient is hemodynamically stable; emerging data suggest EGD is associated with reduced mortality and lower risk of perforation in emphysematous gastritis (OR 0.44, p = 0.021) and should be used in combination with CT rather than as a stand-alone diagnostic approach.

Phlegmonous and Emphysematous Gastritis

Phlegmonous gastritis is a transmural suppurative infection of the gastric wall most frequently caused by Streptococcus species, though gram-negative organisms and polymicrobial infections also occur. Risk factors include immunocompromise, alcohol use disorder, diabetes mellitus, cirrhosis, and prior endoscopic procedures.

When gastric gangrene, free perforation, or failure to improve on intensive antibiotics is identified, emergency surgical intervention is required. The recommended approach is as follows:

1. Exploratory laparoscopy or laparotomy to assess the extent of gastric wall necrosis.
2. Partial gastrectomy for localized necrosis; resection of affected segment with margin-free viable tissue.
3. Total gastrectomy with esophagojejunostomy when necrosis involves the entire stomach or when partial resection would leave nonviable tissue.
4. Intraoperative peritoneal lavage and closed suction drainage for peritonitis or abscess.
5. Continuation of targeted intravenous antibiotics postoperatively based on intraoperative cultures.

Emphysematous gastritis, characterized by intramural gas from gas-forming organisms (most commonly Sarcina ventriculi), carries a historically reported mortality rate of 55%–61%, though with early diagnosis and treatment, mortality has been reduced to approximately 15%–27% in contemporary series. In a systematic review of 116 cases, 79% of patients were managed with medical treatment including antibiotics and supportive care, while 21% required surgical intervention for severe or complicated disease. A proposed algorithmic approach for emphysematous gastritis includes:

1. Diagnosis confirmation by CT scan (sensitivity 95% for intramural gas).
2. Immediate initiation of medical management: NPO, nasogastric tube, broad-spectrum antibiotics (e.g., piperacillin/tazobactam), and antifungal coverage if indicated.
3. Esophagogastroduodenoscopy to assess mucosal ischemia if the patient is hemodynamically stable.
4. In the absence of ischemia: continued non-operative management with close monitoring.
5. If mucosal ischemia is present: exploratory laparoscopy/laparotomy to characterize the degree of ischemia and determine whether partial or complete gastrectomy is required.

Bile Reflux Gastritis

Postgastrectomy bile reflux gastritis arises when disruption of the pyloric sphincter allows duodenal contents to reflux into the stomach, causing mucosal injury. It may follow any procedure altering pyloric function, including partial gastrectomy with Billroth I or Billroth II reconstruction, pyloroplasty, or pyloromyotomy.

Roux-en-Y gastrojejunostomy is the most widely used surgical procedure for bile reflux gastritis and the most satisfactory option when surgical intervention is required. It effectively diverts bile and pancreatic secretions from the gastric remnant. Comparative data from laparoscopic distal gastrectomy show that Roux-en-Y reconstruction is associated with a significantly lower incidence of residual gastritis and bile reflux at 1 and 3 years postoperatively compared with Billroth II reconstruction with Braun enteroenterostomy (p < 0.001).

However, clinicians should be aware of Roux stasis syndrome—a postoperative complication manifesting as postprandial abdominal discomfort, nausea, vomiting, and bezoar formation—which has been reported in approximately 36% of patients undergoing Roux-en-Y gastrojejunostomy on long-term follow-up, despite successful elimination of bile reflux.

In patients who develop bile reflux gastritis following Roux-en-Y gastric bypass for obesity, revisional bariatric surgery—most commonly Roux limb lengthening (56.1%) or gastrogastric fistula takedown (43.9%)—has been shown to provide safe and effective resolution of bile reflux without recurrence on long-term follow-up.

Stress-Related Mucosal Disease with Hemorrhage Refractory to Endoscopy

Stress-related mucosal disease (SRMD) is a spectrum of gastric mucosal injury occurring in critically ill patients. The majority of cases are managed by optimization of the underlying critical illness, enteral nutrition, and pharmacological acid suppression. For patients with clinically important gastrointestinal bleeding unresponsive to endoscopic hemostasis and transcatheter arterial embolization, surgical options include:

• Vagotomy and pyloroplasty with oversewing of bleeding lesions.
• Partial or near-total gastrectomy when hemorrhage is diffuse or uncontrollable.

These procedures carry high operative mortality in the critically ill and should be considered only when all less-invasive modalities have been exhausted.

Long-Term Management

Following surgical intervention for gastritis-related complications, long-term management includes:

• Endoscopic surveillance: Patients with a gastric remnant after partial gastrectomy are at increased risk for gastric remnant carcinoma and require periodic endoscopic surveillance. The interval is generally every 2–3 years beginning 15–20 years after initial surgery, or earlier when high-risk features such as intestinal metaplasia or dysplasia are identified on biopsy.
• Nutritional supplementation: After total or near-total gastrectomy, vitamin B12 (cyanocobalamin) deficiency is universal due to the absence of intrinsic factor; intramuscular vitamin B12 supplementation (1,000 mcg monthly) or high-dose oral supplementation should be instituted. Iron supplementation, calcium, and vitamin D supplementation are typically required.
• OLGA/OLGIM staging: For patients with atrophic gastritis or intestinal metaplasia in the remaining mucosa, risk stratification using the Operative Link on Gastritis Assessment (OLGA) or Operative Link on Gastric Intestinal Metaplasia Assessment (OLGIM) staging systems is recommended to identify patients at elevated risk for gastric adenocarcinoma and to guide endoscopic surveillance intervals.
• Helicobacter pylori eradication: Should be confirmed in all patients with H. pylori-related gastritis. Test-of-cure using urea breath test or stool antigen test should be performed at least 4 weeks after completion of eradication therapy and 2 weeks after cessation of PPI therapy.
• Avoidance of contributing factors: Patients should be counseled to avoid NSAIDs, aspirin (unless medically necessary), excessive alcohol consumption, and cigarette smoking as measures to reduce mucosal injury in the gastric remnant.

Special Populations

Immunocompromised Patients

Immunocompromised patients—including those with HIV/AIDS, on immunosuppressive therapy, receiving chemotherapy, or with advanced diabetes mellitus—are at higher risk for severe and atypical forms of gastritis, including phlegmonous and emphysematous gastritis, and may present insidiously without the classic signs of peritonitis. In a systematic review of phlegmonous gastritis cases, approximately half of reported cases occurred in patients with immunocompromise. A lower threshold for surgical intervention should be maintained in this population. When gastric gangrene is suspected, emergency surgical treatment is warranted.

Pregnant Patients

Phlegmonous gastritis in pregnancy is exceptionally rare. Conservative surgical approaches, including limited debridement rather than extensive resection, have been reported in this population to preserve maternal and fetal well-being, though definitive resection may still be required depending on intraoperative findings.

Post-Bariatric Surgery Patients

Patients who have undergone bariatric surgery—particularly Roux-en-Y gastric bypass—may develop bile reflux gastritis, marginal ulcers, or reactive gastropathy. Management is guided by endoscopic findings, and revisional bariatric surgery should be considered when symptoms are refractory and reflux is confirmed endoscopically. Onset of bile reflux symptoms following Roux-en-Y gastric bypass may occur late (mean onset 58.3 ± 22.2 months postoperatively in one series).