What is the optimal management for a patient with stress gastritis and diffuse gastric bleeding who is in shock after failed endoscopy?

Management of Shock Due to Diffuse Gastric Mucosal Bleeding in Stress Gastritis

In a patient with stress gastritis presenting with shock due to profuse hemorrhage from all over the gastric mucosa after failed endoscopy, immediate surgical intervention is the optimal management.

Rationale for Surgical Management

When dealing with an unstable patient with diffuse gastric mucosal bleeding that has failed endoscopic control, the management algorithm is clear:

1. Hemodynamic Status Assessment

   • The patient is described as being in shock, indicating severe hemodynamic compromise
   • Profuse hemorrhage from "all over the gastric mucosa" indicates diffuse bleeding rather than a focal source

2. Failed Initial Interventions

   • Endoscopy has already been attempted and failed to control bleeding
   • This represents a failure of first-line therapy

3. Evidence-Based Approach

   • According to the World Journal of Emergency Surgery guidelines, "In unstable patients not responding to aggressive resuscitation, diagnostic laparotomy and surgical hemostasis are mandatory" (high quality evidence) 1
   • The guidelines strongly recommend "against delaying surgical exploration in unstable patients presenting with ongoing gastrointestinal bleeding after endoscopic assessment" 1

Why Surgery Over Other Options

Surgery (Option B) vs. Angioembolization (Option A)

While angioembolization may be considered for stable patients, the guidelines clearly state:

• Angioembolization is suggested only for "stable patients presenting with gastrointestinal and intraperitoneal extra-luminal bleeding" 1
• Angiography and angioembolization are described as having "very low" quality of evidence for bleeding control 1
• For unstable patients with diffuse bleeding, surgery provides direct access for definitive hemostasis

Surgery vs. Injection Sclerotherapy (Option C)

Injection sclerotherapy would be inappropriate because:

• It's an endoscopic technique that has already failed in this patient
• Diffuse mucosal bleeding makes targeted sclerotherapy impractical
• Not recommended for unstable patients with ongoing bleeding after failed endoscopy

Surgery vs. Splenectomy (Option D)

Splenectomy would be inappropriate because:

• The bleeding source is clearly identified as diffuse gastric mucosal bleeding
• No evidence suggests splenic involvement in stress gastritis
• Splenectomy would not address the source of hemorrhage

Surgical Approach for Stress Gastritis Bleeding

When performing surgery for diffuse bleeding from stress gastritis:

1. Surgical Planning

   • Intra-operative endoscopy may facilitate localization of bleeding sites 1
   • The surgical approach should be tailored to the diffuse nature of the bleeding

2. Procedural Considerations

   • Conservative surgical approaches like vagotomy and pyloroplasty with oversewing of bleeding erosions may be appropriate 2
   • In severe cases with diffuse bleeding, more extensive procedures may be necessary

Important Caveats

• Timing is Critical: Delay in surgical intervention for unstable patients with ongoing bleeding significantly increases mortality
• Resuscitation: Concurrent aggressive resuscitation with crystalloid fluids and blood products should be initiated while preparing for surgery
• Post-Surgical Care: After surgical control, continued acid suppression therapy and addressing underlying causes of stress gastritis remain essential

Prevention of Recurrence

After surgical control of bleeding:

• Continue acid suppression therapy with PPIs or H2 receptor antagonists 3
• Address underlying conditions that contributed to stress gastritis
• Monitor for rebleeding and complications

In this scenario with a shocked patient and diffuse bleeding after failed endoscopy, immediate surgical intervention represents the most appropriate management strategy to reduce mortality.