Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-22: Gastritis & Gastropathy + Key Features Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ 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 beta-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 remains > 90 mm Hg and patient has no side effects +++ Therapeutic Procedures ++ Portal hypertensive gastropathy: portal decompressive procedures, eg, transvenous intrahepatic portosystemic shunts, are sometimes required for acute hemorrhage + Outcome Download Section PDF Listen +++ +++ Complications ++ Acute upper GI hemorrhage Chronic GI blood loss with anemia +++ Prevention ++ Stress gastritis Intravenous H2-receptor antagonists and proton pump inhibitors (oral or intravenous) have been shown to reduce the incidence of clinically overt and significant bleeding but may increase the risk of nosocomial pneumonia Optimal, cost-effective prophylactic regimens are uncertain, hence clinical practice varies For patients with nasoenteric tubes, immediate-release omeprazole (40 mg at 1 and 6 hours on day 1; then 40 mg once daily beginning on day 2) may be preferred because of lower cost and ease of administration For patients requiring intravenous administration, continuous intravenous infusions of H2-receptor antagonists provide adequate control of intragastric pH in most patients in the following doses over 24 hours: cimetidine (900–1200 mg) or famotidine (20 mg) Alternatively, intravenous proton pump inhibitors, though more expensive, may be preferred due to superior efficacy The optimal dosing of intravenous proton pump inhibitors is uncertain, however in clinical trials pantoprazole doses ranging from 40 mg to 80 mg and administered every 8 or every 24 hours appear equally effective +++ When to Refer ++ NSAID gastritis with persistent dyspepsia despite discontinuation of NSAIDs or empiric therapy All patients with alarm symptoms (severe pain, weight loss, vomiting, anemia, melena) should be referred for upper endoscopy Clinically significant acute upper GI hemorrhage +++ When to Admit ++ NSAID gastritis Acute upper GI hemorrhage Severe dyspepsia with concern for complicated peptic ulcer disease or alternative diagnosis Alcoholic gastritis with protracted vomiting and/or acute upper GI hemorrhage or signs of alcohol withdrawal Portal hypertensive gastropathy with acute upper GI hemorrhage + References Download Section PDF Listen +++ + +Alshamsi F et al. Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials. Crit Care. 2016 May 4;20(1):120. [PubMed: 27142116] + +Bardou M et al. Stress-related mucosal disease in the critically ill patient. Nat Rev Gastroenterol Hepatol. 2015 Feb;12(2):98–107. [PubMed: 25560847] + +Buendgens L et al. Prevention of stress-related ulcer bleeding at the intensive care unit: risks and benefits of stress ulcer prophylaxis. World J Crit Care Med. 2016 Feb 4;5(1):57–64. [PubMed: 26855894] + +Krag M et al; SUP-ICU trial group. Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med. 2018 Dec 6;379(23):2199–208. [PubMed: 30354950]