Acute haemorrhagic gastritis: modern concepts based on pathogenesis.

Acute haemorrhagic gastritis is one of the most frequent causes of severe upper gastrointestinal haemorrhage. In series in which a positive diagnosis is made by endoscopy or laparotomy the incidence is approximately 25 %1,2,3. It is frequently related to recent aspirin ingestion5 and is also seen after major surgery or trauma ('stress' ulcers),6 but may occasionally appear in the absence of any apparent cause. Acute haemorrhagic gastritis is a condition of acute diffuse superficial erosions (not extending deeper than the muscularis mucosae) or multiple petechial haemorrhages of the mucosa of the stomach usually confined to, or predominant in, the fundal region. Gastroscopically, the mucosa of the body of the stomach is uniformly red and oozing blood. This picture may change rapidly so that 24 to 48 hours after bleeding has stopped the mucosa may appear normal. A similar appearance is seen in severely ill patients after major surgery or trauma6. In the latter case, the gastric lesions have often been referred to as 'stress ulcers', a term which has caused some confusion with classical Cushing's7 (neurosurgical) or Curling's8'9 (burns) ulcers in which there is a deeper lesion resembling a normal peptic ulcer. Patients with neurosurgical lesions or burns may, however, bleed from acute haemorrhagic gastritisg. Acid output in acute haemorrhagic gastritis is decreased. In Cushing's or Curling's ulcer it is either increased or normal9, suggesting a different pathogenesis for the two conditions. Even in the presence of other radiologically demonstrable lesions acute haemorrhagic gastritis must be excluded (by gastroscopy) as the cause of bleeding. In a review of 618 patients already known to have a potentially bleeding lesion in the upper gastrointestinal tract when the current haemorrhage began, 40% were bleeding from some other lesion'0. In a recent series from the Boston City Hospital of 18 patients with acute bleeding and demonstrable varices, bleeding from gastritis was the most common finding (60 %)". Varices were the cause of bleeding in only 20%. This will not be recognized unless a positive diagnosis by gastroscopy is sought in all cases of acute upper gastrointestinal tract bleeding. In patients bleeding massively from acute haemorrhagic gastritis (defined in one series'2 as serum Hb < 8.0 g % and average transfusion requirement of 21 units blood) the mortality is upwards of 50 %12. If surgery is required then in many cases radical surgery ranging from hemigastrectomy ± vagotomy to total gastrectomy'2"13"14"516 is required. There have been some enthusiastic reports of the results of vagotomy and pyloroplastyl7"18 but this has not proved satisfactory in all handsg'12"6.