Erosive Gastritis

Aka: Erosive Gastritis, Hemorrhagic Gastritis, Multiple Gastric Erosions, Stress Ulcer, Gastrointestinal Prophylaxis, Prophylaxis Against Gastrointestinal Ulcer, Gastric Ulcer Prophylaxis, Gastric Ulcer Prevention in Patients with Critically Illness, Gastroprotection, Peptic Ulcer Disease Prevention

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II. Causes

  1. See Peptic Ulcer Disease
  2. Medications
    1. Aspirin
    2. NSAIDs
    3. Alcohol
  3. Severe stress (mucosal protection breaks down, allows for splanchnic hypoperfusion)
    1. Burns
    2. Sepsis
    3. Trauma
    4. Surgery
    5. Shock
    6. Respiratory Failure
    7. Renal Failure
    8. Liver failure
    9. Mechanical Ventilation

III. Symptoms (May be asymptomatic)

  1. Epigastric discomfort
  2. Nausea or Vomiting
  3. Hematemesis
  4. Melena

IV. Signs

  1. See Peptic Ulcer Disease
  2. Epigastric tenderness

V. Diagnosis

  1. Upper endoscopy (EGD)
    1. Mucosal inflammation and engorgement
    2. Erosions and Hemorrhages
  2. Upper GI barium study
    1. Thickened rugae

VI. Management

  1. See Acute Gastrointestinal Bleeding Management
  2. See Peptic Ulcer Disease
  3. ABC Management first

VII. Prevention: GI Prophylaxis in Outpatients on Antiplatelet Agents or Anticoagulants (Gastroprotection)

  1. Indications: Antiplatelet Agents or Anticoagulants (Aspirin, Apixaban, Warfarin) AND
    1. Second Antiplatelet or Anticoagulant
    2. Prior upper gastrointestinal bleed
    3. Higher dose Corticosteroids (lower doses may not require prophylaxis)
    4. NSAIDs
  2. Approach
    1. Proton Pump Inhibitor or H2 Blocker
    2. Stop GI prophylaxis when Anticoagulants or antiplatelet agents are discontinued
    3. Reevaluate indications for Anticoagulant and antiplatelet agents at routine clinic visits
    4. Eliminate other causes of Peptic Ulcer (e.g. Alcohol, NSAIDS, Tobacco)
  3. Precautions
    1. Continuous acid suppression (esp. Proton Pump Inhibitor) carries many risks including Clostridium difficile

VIII. Prevention: GI Prophylaxis in Critically Ill Hospitalized Patients (ICU)

  1. Indications: High risk patients in ICU
    1. Mechanical Ventilation
    2. Coagulopathy
    3. Multiple Traumatic injuries
    4. Recent Gastrointestinal Bleeding
    5. High dose Corticosteroids (equivalent to Prednisone 60 mg/day)
  2. Protocol
    1. Start GI prophylaxis in high risk ICU patients
      1. Risk of stress-ulcer related GI Bleeding in the ICU: 25%
    2. Discontinue prophylaxis on transfer out of Intensive Care unit
      1. Risk of Stress Ulcer related GI Bleeding drops to <1% outside the ICU
  3. General Measures
    1. Avoid NSAIDS in ICU patients
    2. Stop Aspirin in primary prevention (no known Coronary Artery Disease)
    3. Initiate early Enteral Nutrition
  4. Option 1: Maintain gastric pH > 4
    1. Proton Pump Inhibitor (PPI)
      1. Preparations
        1. Omeprazole (Prilosec) 20-40 mg orally daily
        2. Pantoprazole (Protonix) 40 mg IV daily
      2. Adverse effects
        1. Risk of Nosocomial Pneumonia (Protect against Aspiration Pneumonia)
        2. Risk of Clostridium difficile
      3. Efficacy
        1. May be more effective than H2 Blockers in ICU Stress Ulcer related GI Bleeding (variable evidence)
          1. Alhazzani (2013) Crit Care Med 41(3): 693-705 [PubMed]
    2. H2 Antagonist IV infusion
      1. Preparations
        1. Famotidine 20 mg IV every 12 hours
        2. Ranitidine 50 mg IV every 8 hours
        3. Avoid Cimetidine due to Drug Interactions
        4. Modify dose when GFR <50ml/min
      2. Efficacy
        1. May be preferred over PPI with fewer adverse effects
        2. Some studies suggest similar efficacy in prevention of GI Bleeding
        3. (2014) Presc Lett 21(4): 24
        4. MacLaren (2014) Crit Care Med 42(4): 809-15 [PubMed]
  5. Option 2: Topical protectants
    1. Sucralfate (Carafate) slurry 1 g PO q6h
    2. Misoprostol 200 ug PO qid
    3. Less risk of Aspiration Pneumonia than Option 1

IX. References

  1. Marino (2014) ICU Book, p. 77-88
  2. Internet Book of Critical Care (Farkas, EM-Crit)
    1. https://emcrit.org/ibcc/guide/
  3. (2022) Presc Lett 29(9): 53

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