acute hemorrhagic 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

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