Gastritis, Erosive & Hemorrhagic

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 ...