Gastritis, Erosive & Hemorrhagic

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

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

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

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

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