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Key Features

Essentials of Diagnosis

  • May cause hematemesis; usually not significant bleeding

  • Often asymptomatic; may cause epigastric pain, anorexia, nausea, and vomiting

  • Occurs most commonly in alcoholic or critically ill patients, or patients taking nonsteroidal anti-inflammatory drugs (NSAIDs)

General Considerations

  • Most common causes

    • Drugs (especially NSAIDs)

    • Alcohol

    • Stress due to severe medical or surgical illness

    • Portal hypertension ("portal gastropathy")

  • Uncommon causes

    • Ischemia

    • Caustic ingestion

    • Radiation

  • Major risk factors for stress gastritis

    • Mechanical ventilation

    • Coagulopathy

    • Trauma

    • Burns

    • Shock

    • Sepsis

    • Central nervous system injury

    • Liver failure

    • Kidney disease

    • Multiorgan failure

  • The use of enteral nutrition reduces the risk of stress-related bleeding

Demographics

  • Patients using NSAIDs, especially aspirin, short- or long-term

  • Heavy alcohol ingestion

Clinical Findings

Symptoms and Signs

  • Often asymptomatic

  • Symptoms, when they occur, include dyspepsia, anorexia, epigastric pain, nausea, and vomiting

  • Upper gastrointestinal (GI) bleeding, hematemesis, "coffee grounds" emesis, bloody aspirate in a patient receiving nasogastric suction, or melena

  • Bleeding is not usually hemodynamically significant

Differential Diagnosis

  • Epigastric pain suggests

    • Peptic ulcer

    • Gastroesophageal reflux

    • Gastric cancer

    • Biliary tract disease

    • Food poisoning

    • Viral gastroenteritis

    • Functional dyspepsia

  • Severe pain suggests

    • Perforated or penetrating ulcer

    • Pancreatic disease

    • Esophageal rupture

    • Ruptured aortic aneurysm

    • Gastric volvulus

    • Gastrointestinal ischemia

    • Myocardial ischemia

  • Upper GI bleeding suggests

    • Peptic ulcer disease

    • Esophageal varices

    • Mallory-Weiss tear

    • Angiodysplasias

Diagnosis

Laboratory Tests

  • Hematocrit is low if significant bleeding

  • Iron deficiency

Imaging Studies

  • Upper endoscopy for dyspepsia or upper GI bleeding is diagnostic

    • Subepithelial hemorrhages, petechiae, and erosions

    • These lesions are superficial, vary in size and number, and may be focal or diffuse

  • Barium upper GI series is insensitive because abnormalities are confined to the mucosa

Diagnostic Procedures

  • Nasogastric tube placement reveals bloody aspirate

Treatment

Medications

  • Treatment of clinically significant upper GI bleeding due to stress-related gastritis, alcoholic gastritis, or NSAID gastritis

    • Proton pump inhibitors may be used; however, efficacy and optimal dosing strategy are unknown

    • Once bleeding occurs, administer continuous infusions of a proton pump inhibitor (esomeprazole or pantoprazole, 80 mg intravenous bolus, followed by 8 mg/h continuous infusion) as well as sucralfate suspension 1 g orally 4 times daily

  • Empiric treatment of dyspepsia (without alarm symptoms) caused by NSAIDs

    • Proton pump inhibitor (omeprazole, rabeprazole, or esomeprazole 20–40 mg/day; lansoprazole or dexlansoprazole, 30 mg/day; pantoprazole, 40 mg/day) orally for 2–4 weeks

  • Treatment of dyspepsia or minor upper GI hemorrhage caused by alcoholic gastritis: oral H2-receptor antagonists, proton pump inhibitor, or sucralfate for 2–4 weeks

  • Portal hypertensive gastropathy

    • Nonselective β-blocker (propranolol or nadolol)

    • Dose adjusted every 1–2 weeks until heart rate falls by 25% or reaches 55 beats/min, providing that systolic blood pressure ...

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