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acute hemorrhagic gastritis

Thursday 27 December 2012

acute haemorrhagic gastritis

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


- erosive gastritis
- gastric hyperemic edematous mucosa
- gastric mucosal bleeding
- gastric mucosal erosions (erosibe gastritis)
- gastric mucosal aphthous ulcerations
- gastric parietal perforation (rare)


- 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


- 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


- Supportive

  • Removal of causative agents
  • Correction of underlying problem (shock, trauma)

- Gastrectomy if hemorrhage uncontrollable

  • Approximately 5% of cases


- Rapid resolution after correction of etiology
- Overall prognosis dictated by patient’s general status


- 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