I have ‘GASTRITIS’, Doctor!

Most, if not all, practitioners of Medicine in Sri Lanka, I believe, would surely have come across patients presenting with the above complaint.

I find this rather strange, since, for over two decades of practicing medicine outside Sri Lanka, I have never, (that’s right, never) not once, had a patient complaining of “Gastritis”. Thus, this complaint, endemic in our country, appears to be a uniquely Sri Lankan phenomenon and merits reflection and thought.

I find that the manner in which this complaint is made to some extent reflects the individual’s educational and socioeconomic standard. Thus, white collar worker types, present with the standard “I have gastritis, doctor” (mata hariata gastritis, doctor). Blue collar workers come, saying, ” I have gastric, doctor” (mata hondatama gastric thiyenawa, sir).

Then finally there is the classic lady in her late sixties or early seventies,(she runs the corner grocery shop- “podi sillara kadayak dala thiyanawa, sir,) dressed in white blouse with lace trimmings and a printed cloth,(admittedly a fast disappearing dress code!), generally overweight, with betel stained teeth, who waddles into the consultation room and plonks herself on a chair like a beached whale and comes out with, “Sir, mata Gas -Trick thiyanawa!” Now, this is said with a triumphant, almost challenging smirk on her face as if to say “There, now, sort that trick if you’re so clever”. I find myself cringing, reduced to a nail biting, quivering mass of flesh, not knowing how to respond!!

Seriously, folks, “Gastritis” is not a SYMPTOM; it’s a condition where the lining of your stomach is abnormal, and can accurately be diagnosed only by looking into your stomach with an endoscope. Not even then sometimes, the endoscopist may have to take bits of tissue and look at it under the microscope to diagnose “Gastritis”.

Thus, if I were to draw an analogy, when you have a headache, for example, you don’t tell your doctor, “I have migraine, or a tension headache, or meningitis, or Benign Intracranial Hypertension or Brain tumour”, do you? Of course, you don’t. You just say I have a headache! Your doctor will then try to ascertain what the headache is due to. Another example, if you have chest pain, you’re not going to tell the doctor “I have Pericarditis, or Pleurisy, or Costochondritis, or I’m having a Myocardial Infarct, or Intercostal neuralgia”? No, you don’t, you just tell him your SYMPTOM, which is chest pain. (I have deliberately used some medical terms readers may not be familiar with, to drive home my point.).

In fact, if you do have Gastritis, it can produce symptoms like, discomfort or pain in the tummy, nausea, bloating, early satiety and so on, but the point is that these symptoms can be due to a whole variety of other conditions, and to conclude that Gastritis is the underlying cause is often quite misleading. There are a few occasions where one might correctly self-diagnose “gastritis”. Thus if you have had a bout of heavy alcohol drinking, you may have alcoholic gastritis, or if you have accidentally swallowed dishwashing liquid or other household cleaning agent, you may have a chemical gastritis, or if you have been taking pills like anti-inflammatory drugs for a while you may have a drug induced gastritis ,

Some patients who have presented with the infamous ‘i have gastritis” complaint have in fact turned out to have a completely different diagnosis, Reflux Oesophagitis, Biliary Colic, Irritable Bowel Syndrome, Acute Pancreatitis, Gastroenteritis, Acute appendicitis ,Diverticulitis, are some examples that come to mind, and some of these are quite serious illnesses unlike the much-maligned “Gastritis”.

Well researched studies have shown that over fifty percent of patients attending gastroenterology clinics, in fact have what are medically called “functional disorders” .This means that there is no demonstrable structural abnormality in the organ under study, (in this case the stomach and intestinal tract mainly),but that its functioning is not normal. Many of the symptoms attributed to “Gastritis” mentioned earlier are due to these types of “functional disorders.”

There are nerve impulses travelling to and fro, from parts of the brain to the intestinal tract, the ‘’Brain Gut Axis”. This Brain Gut Axis and its functioning is still not fully understood, but to put it simply, it’s when this is out of sync that a number of functional disorders of the bowel arise. It’s a common experience when under intense stress you feel your “stomach knotted up” or you feel like “throwing up”, due to these nerve connections between the brain and intestinal tract. ‘Visceral Hypersensitivity’ is another concept which explains many functional disorders of the intestinal tract. Here, in some individuals, normal impulses that arise – for example when the bowel is filled with gas – is perceived as a painful sensation in those with visceral hypersensitivity (perhaps an oversimplified explanation).

When you tell your doctor, I have gastritis (particularly if he’s very busy and hasn’t much time to listen ) you’ll invariably be prescribed two types of drugs, an acid suppressant also called a Proton Pump Inhibitor, which reduces acid secretion in the stomach and a “pro kinetic ” drug, which helps emptying of the stomach, and you’ll end up popping these pills in your mouth for months! A small percentage of patients may actually need these medications, but the majority have “Functional disorders”, incorrectly attributed to “Gastritis”, and what is needed is an explanation of the harmless nature of the symptom, and perhaps a few lifestyle changes. The true beneficiary of these medications are of course the drug companies, who’ll be laughing all the way to the bank!

How did the term ‘Gastritis’ come to be so widely used/misused? In the late eighties, this was a complaint we hardly heard of. At the time Endoscopy services were not widely available in Sri Lanka, unlike the present time. With the increasing use of endoscopy, it’s quite common to find some degree of “gastritis”, which is an endoscopic diagnosis and does not result in clinical symptoms. Secondly, patients may feel they don’t want to waste time of a busy doctor, and instead of describing their symptoms, just say that they have “gastritis”.

The major culprits responsible for misuse of the term “gastritis” is of course the medical profession itself! Particularly practitioners, who have what I call the “Next Patient Syndrome”! In so much of a hurry to see the next patient, it’s much easier to say “you have gastritis” for any tummy problem, and prescribe a few drugs; than to give a long-winded explanation on the lines mentioned earlier.

I must end with this classic example illustrating the misuse of “gastritis”. A patient rang me recently saying “Doctor, my friend’s mother has high blood pressure and has got a sudden headache and is now vomiting” and before I could say, OMG, she could be having a Sub Arachnoid bleed, (type of bleeding inside the skull) she goes, ‘Doctor, can you give something for her gastritis, because she’s vomiting!” That telephone conversation ended sharply. Need I say more?

So, folks, let’s do the “In thing” and have a “system change”, and use the term Gastritis, as it should be!

N. J.

Consultant Physician, Internal Medicine and Gastroenterology