Causes of Hemorrhagic Gastritis Beyond NSAIDs
Beyond NSAIDs, hemorrhagic gastritis can be caused by alcohol abuse, corticosteroid use, anticoagulants, H. pylori infection, physiologic stress from critical illness, radiation therapy, and portal hypertension. 1, 2
Major Non-NSAID Causes
Medications and Substances
- Alcohol consumption: A significant cause of acute hemorrhagic gastritis 2
- Corticosteroids: Increase risk of GI bleeding, especially when combined with NSAIDs 1, 3
- Anticoagulants/antiplatelet drugs: Significantly increase bleeding risk, with a 10-fold higher risk when combined with NSAIDs 1, 3
- Multiple medication combinations: Concomitant use of NSAIDs with anticoagulants or other NSAIDs (including low-dose aspirin) dramatically increases risk 1
Infectious Causes
- Helicobacter pylori infection: Increases risk of upper GI complications by 2-4 fold 1
- H. pylori has surpassed NSAIDs as the most commonly identified risk factor among patients with bleeding ulcers in some studies 1
Physiologic Stress
- Critical illness: Severe trauma, burns, sepsis, or multi-organ failure 4, 2
- Major surgery: Particularly in ICU settings 2
- Mechanical ventilation: Associated with stress-related mucosal damage 2
Other Causes
- Radiation therapy: Can cause radiation-induced hemorrhagic gastritis, particularly challenging to manage 5
- Portal hypertension: Associated with increased risk of hemorrhagic gastritis 2
- Advanced age: Increases risk approximately 4% per year 1, 3
- History of previous ulcer disease: Strongest risk factor for GI complications 1
Risk Stratification
Risk factors for hemorrhagic gastritis can be categorized as:
- Low risk: Absence of risk factors 1
- Moderate risk: 1-2 risk factors 1
- High risk: Multiple risk factors or concomitant use of aspirin, steroids, or anticoagulants 1
- Very high risk: History of prior ulcer complications 1
Clinical Course and Management
The clinical course of hemorrhagic gastritis varies significantly:
- Mild, self-limited illness: When associated with gastric irritants like alcohol or NSAIDs 4
- Life-threatening massive hemorrhage: When associated with stress in critically ill patients 4
Management principles include:
- Early endoscopic diagnosis
- Withdrawal of offending agents
- Reduction of gastric acidity
- Intensive organ system support when needed 4
Prevention Strategies
For patients at risk of hemorrhagic gastritis:
- H. pylori testing and eradication: Recommended for all patients requiring regular NSAID therapy 1
- Gastroprotection: Use of proton pump inhibitors (PPIs) in high-risk patients 1, 3
- Avoidance of medication combinations: Particularly NSAIDs with anticoagulants, steroids, or other NSAIDs 1, 3
Clinical Pitfalls and Caveats
- Hemorrhagic gastritis may be asymptomatic until significant bleeding occurs - only one in five patients with serious upper GI adverse events on NSAID therapy is symptomatic 6
- The risk of bleeding complications increases with longer duration of treatment 3
- Enteric coating or buffering of medications like aspirin does not eliminate the risk of GI complications 1
- Even low-dose aspirin (81-325 mg/day) used for cardiovascular protection increases GI risk 2-4 times 1
Recognizing these multiple potential causes of hemorrhagic gastritis is essential for proper risk assessment, prevention, and management in clinical practice.