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acute hemorrhagic gastritis

Thursday 27 December 2012

acute haemorrhagic gastritis
A Definition: An erosive gastritis due to imbalance between physiologic mucosal protection and causative noxious agents or mechanisms. Incidence: Significant proportion of intensive care unit patients (20% will develop overt bleeding) Clinical synopsis - Natural history depends on etiology - Hematemesis - Acute gastroenteritis-like illness - Epigastric pain - Acute gastroenteritis-like illness Macroscopy - erosive gastritis - gastric hyperemic edematous mucosa - gastric mucosal bleeding - gastric mucosal erosions (erosibe gastritis) - gastric mucosal aphthous ulcerations - gastric parietal perforation (rare) Microscopy - congestion of gastric mucosal capillaries (dilatation of gastric mucosal capillaries ) - gastric mucosal interstitial hemorrhage - gastric mucosal interstitial edema - gastric mucosal epithelial erosions - gastric mucosal interstitial fibrin aggregates - gastric mucosal interstitial neutrophils - gastric mucosal limited inflammation - gastric mucosal regenerative epithelial changes - gastric diffuse mucosal erosion with effacement of the normal epithelium. - gastric mucosal basal residual glands are seen. - gastric mucosal residual regenerative epithelial elements. -* The gastric mucosal basal reactive atypia should not be mistaken for gastric mucosal epithelial dysplasia (dysplastic changes.) -* - gastric mucosal mucin-depleted reactive epithelium - Necrotic cells are sloughed off in the lumen. - edematous and inflamed gastric mucosa with reactive changes. - The lamina propria expanded by a mixed inflammatory infiltrate. - neutrophilic superficial exudate. Differential diagnosis - Acute CMV Gastritis -* Look for cytomegalovirus ("owl’s-eye") intranuclear inclusion bodies and intracytoplasmic inclusion bodies -* Cytomegalovirus immunohistochemical stain may prove helpful - Acute Herpetic Gastritis -* Look for ground-glass nuclei and eosinophilic intranuclear inclusion bodies surrounded by halos -* Herpes simplex virus immunohistochemical stain may prove helpful - H. pylori and H. felis Infection -* Look for organisms within mucus layer -* Helicobacter pylori immunohistochemical stain may prove helpful - Low-Grade Epithelial Dysplasia -* In comparison to reactive changes, nuclear hyperchromasia, stratification, and overlapping are noted on surface - Subtle cases may mimic biopsy trauma -* Fibrin and reactive epithelium are key to diagnosis Natural History - Varies depending on etiology Etiology - Various etiologies -* Ischemia related to shock/hypotension or release of vasoconstrictive substances in ICU patients -* Gastrotoxic drugs and caustic agents - Ischemia -* Shock -* Severe stress -** Trauma and burns associated with hypotensive events or release of vasoconstrictive substances -* Trauma -* Cocaine -* Chemotherapy and radiation therapy - Toxins and Drugs -* Large doses of NSAIDs -* Other gastrotoxic drugs -** Steroids -** iron pills -** bisphosphonates -* Caustic agents -** Acid and alkali in suicide attempts -* Binge drinking Differential Diagnosis - acute infectious gastritis - acute Helicobacter pylori infection - low-grade epithelial dysplasia Treatment - Supportive -* Removal of causative agents -* Correction of underlying problem (shock, trauma) - Gastrectomy if hemorrhage uncontrollable -* Approximately 5% of cases Prognosis - Rapid resolution after correction of etiology - Overall prognosis dictated by patient’s general status References - Srivastava A et al: Pathology of non-infective gastritis. Histopathology. 50(1):15-29, 2007 - Wada S et al: Endoscopic hemostasis for radiation-induced gastritis using argon plasma coagulation. J Gastroenterol Hepatol. 18(10):1215-8, 2003 - Graham DY: What the gastroenterologist should know about the gastrointestinal safety profiles of bisphosphonates. Dig Dis Sci. 47(8):1665-78, 2002 - Wolfe MM et al: Gastrointestinal toxicity of nonsteroidal antiinflammatory drugs. N Engl J Med. 340(24):1888-99, 1999 - Kodali VP et al: Gastrointestinal hemorrhage secondary to crack cocaine. Gastrointest Endosc. 41(6):604-5, 1995 - Chamberlain CE: Acute hemorrhagic gastritis. Gastroenterol Clin North Am. 22(4):843-73, 1993 - Laine L et al: Histology of alcoholic hemorrhagic "gastritis": a prospective evaluation. Gastroenterology. 94(6):1254-62, 1988 - Laine LA et al: Effect of oral iron therapy on the upper gastrointestinal tract. A prospective evaluation. Dig Dis Sci. 33(2):172-7, 1988 - Weidner N et al: Peptic ulceration with marked epithelial atypia following hepatic arterial infusion chemotherapy. A lesion initially misinterpreted as carcinoma. Am J Surg Pathol. 7(3):261-8, 1983