What is the management and treatment approach for a patient with severe gastritis and hyperemesis (vomiting) after a diclofenac (Non-Steroidal Anti-Inflammatory Drug (NSAID)) injection?

Management of Severe Gastritis and Hyperemesis Following Diclofenac Injection

Immediate discontinuation of diclofenac and implementation of aggressive antiemetic therapy with proton pump inhibitors is the cornerstone of management for severe gastritis and hyperemesis following diclofenac injection. 1, 2

Initial Management

1. Discontinue diclofenac immediately

   • NSAIDs including diclofenac are known to cause gastric mucosal damage through both topical and systemic effects 2, 3
   • Continued exposure will worsen gastritis and vomiting

2. Fluid resuscitation and electrolyte correction

   • Intravenous fluid replacement to correct dehydration from severe vomiting
   • Monitor and correct electrolyte abnormalities, particularly after 50 episodes of vomiting 1

3. Antiemetic therapy (first-line options)

   • Parenteral 5-HT3 antagonist: Ondansetron 4-8 mg IV/IM every 8 hours 1, 4
   • Dopamine receptor antagonist: Metoclopramide 10 mg IV/IM every 8 hours or haloperidol 0.5-2 mg IV/IM 1
   • Consider combination therapy for severe cases

4. Gastric acid suppression

   • Proton pump inhibitor: High-dose IV (e.g., pantoprazole 80 mg IV bolus, then 8 mg/hr infusion) 1
   • More effective than H2 receptor antagonists for NSAID-induced gastritis 1, 5

Second-line Management for Refractory Cases

1. Additional antiemetic options

   • Corticosteroids: Dexamethasone 4-8 mg IV 1
   • Benzodiazepines: Lorazepam 0.5-2 mg IV for anxiety-related nausea 1
   • Anticholinergics: Scopolamine transdermal patch 1

2. Alternative administration routes

   • Consider rectal or transdermal antiemetics if oral route not feasible due to continued vomiting 1
   • Nasal sprays may provide acute delivery of agents for breakthrough emesis 1

3. Consider endoscopy

   • Indicated in patients with alarm symptoms (severe vomiting, bleeding) 1
   • Allows direct visualization of gastric mucosa and assessment of damage severity
   • Can rule out complications like ulceration or perforation

Ongoing Management

1. Transition to oral medications once vomiting controlled

   • Oral PPI (e.g., omeprazole 40 mg twice daily) 5
   • Oral antiemetics as needed

2. Gastroprotective agents

   • Consider misoprostol (prostaglandin analog) to enhance mucosal protection 1, 5
   • Sucralfate to coat and protect damaged mucosa 5

3. Nutritional support

   • Clear liquids initially, progressing to bland diet as tolerated
   • Small, frequent meals to minimize gastric distension

Prevention of Future Episodes

1. Avoid all NSAIDs if possible

   • Consider alternative analgesics (acetaminophen) 2
   • If NSAIDs required, use lowest effective dose with gastroprotection 1, 2

2. If NSAIDs must be continued

   • Always co-administer with PPI 1
   • Consider COX-2 selective NSAIDs which may have lower GI risk 1, 2
   • Consider topical NSAID formulations when appropriate 2

Special Considerations

• Elderly patients have higher risk of NSAID-induced gastritis and complications 1
• Patients with history of peptic ulcer disease should avoid NSAIDs if possible 1
• Concomitant use of corticosteroids or anticoagulants increases risk of GI complications 1

Common Pitfalls to Avoid

1. Continuing NSAID therapy during acute gastritis episode
2. Inadequate fluid resuscitation in severely dehydrated patients
3. Using single antiemetic agent when combination therapy may be more effective for severe hyperemesis
4. Premature oral intake before vomiting is adequately controlled
5. Failure to monitor for complications such as GI bleeding or perforation

The evidence strongly supports aggressive management of NSAID-induced gastritis with immediate discontinuation of the offending agent, combined with antiemetic therapy and acid suppression. Early intervention can prevent complications and reduce morbidity associated with severe gastritis and hyperemesis.