What is the management strategy for hemorrhagic gastritis?

Management of Hemorrhagic Gastritis

Hemorrhagic gastritis should be managed with aggressive acid suppression using high-dose intravenous proton pump inhibitors (80 mg omeprazole bolus followed by 8 mg/hour infusion for 72 hours), combined with hemodynamic resuscitation, early endoscopy within 12 hours, and endoscopic hemostatic therapy when active bleeding is identified. 1

Initial Resuscitation and Stabilization

• Maintain restrictive transfusion targets: Keep hemoglobin at 70-90 g/L (trigger at 70 g/L) in patients without cardiovascular disease, or 80-100 g/L in those with cardiac history 1
• Provide intravascular volume support with crystalloids and blood products as needed to achieve hemodynamic stability 2
• Monitor continuously with pulse, blood pressure, and urine output measurements following initial stabilization 1

Pharmacological Therapy

Proton Pump Inhibitors (First-Line)

• Administer high-dose omeprazole: 80 mg IV bolus followed by continuous infusion of 8 mg/hour for 72 hours after successful endoscopic therapy 1
• This regimen reduces rebleeding rates, blood transfusion requirements, and hospital stay duration 1
• Continue oral PPI therapy after the initial 72-hour period until complete healing is confirmed 1

Alternative Agents

• Somatostatin may be considered as it suppresses acid secretion and reduces splanchnic blood flow, though evidence quality is limited 1
• Historical use of cimetidine showed efficacy in controlling bleeding (12 of 13 patients stopped bleeding), though modern PPIs are preferred 3

Endoscopic Management

Timing and Approach

• Perform upper endoscopy within 12 hours of presentation once hemodynamic stability is achieved 1, 2
• Endoscopy serves dual purposes: diagnostic confirmation and therapeutic intervention 1

Endoscopic Therapy Options

• Thermal hemostasis using heater probes or multipolar coagulation achieves primary hemostasis in up to 95% of patients with GI bleeding 4
• Apply 20-30 joules repeatedly until a blackened area forms, combining pressure (tamponade) and heat 4
• Injection therapy or combination approaches may be used for focal bleeding points 1

Repeat Endoscopy Indications

• Clinical evidence of rebleeding (fresh melena, hematemesis, hemodynamic instability) 1
• Concerns about suboptimal initial therapy in actively bleeding patients 1
• Consider repeat intervention 12-24 hours later if initial therapy was difficult 1

Management of Refractory Bleeding

Second Endoscopic Attempt

• Perform repeat endoscopy to confirm rebleeding and attempt endoscopic therapy once more if stigmata persist 1
• Do not proceed beyond one repeat endoscopic intervention if unsuccessful 1

Radiological Intervention

• CT angiography should be performed if patient remains unstable (shock index >1) or active bleeding is suspected despite endoscopic therapy 1
• Catheter angiography with embolization should follow positive CTA within 60 minutes in unstable patients at centers with 24/7 interventional radiology 1

Surgical Options (Last Resort)

• Surgery is reserved for patients with uncontrolled hemorrhage despite endoscopic and radiological interventions 1
• Vagotomy combined with subtotal gastrectomy offers best protection against rebleeding, though mortality remains high at approximately 30% 5, 6
• Total gastrectomy provides definitive cure but should be considered only as a second procedure after conservative surgery fails, particularly in elderly patients 6
• Minimum operation (local excision or underrunning) should be performed in elderly patients with poor physical condition 1

Addressing Underlying Causes

Risk Factor Modification

• Discontinue NSAIDs and aspirin if these are contributing factors 1
• Test and treat for H. pylori as eradication makes rebleeding extremely rare 1
• Address alcohol abuse and manage portal hypertension if present 7
• Treat physiologic stress in ICU patients, as stress is a major predisposing factor 7, 8

Medication Management After Hemostasis

• If NSAIDs must be continued, use ibuprofen (least damaging) with a PPI 1
• Consider COX-2 selective anti-inflammatory drugs as an alternative 1

Post-Stabilization Care

• Allow oral intake 4-6 hours after endoscopy if patient is hemodynamically stable; prolonged fasting is unnecessary 1
• Continue PPI therapy until complete mucosal healing is documented 1
• Repeat endoscopy at 6 weeks for gastric lesions to confirm healing and exclude malignancy 1

Common Pitfalls to Avoid

• Do not delay endoscopy beyond 12 hours, as early intervention improves outcomes 1, 2
• Do not proceed to emergency laparotomy without exhausting radiological and endoscopic options 1
• Avoid operating between midnight and 7am when possible, as timing affects outcomes 1
• Do not use routine prophylactic endoscopy after initial treatment unless specific concerns exist 1