Acute erosive gastritis

　　1. Etiology

　　Various exogenous stimuli that cause acute simple gastritis, especially ethanol and non-steroidal anti-inflammatory drugs, can destroy the gastric mucosal barrier, leading to the reverse diffusion of H and pepsin into the mucosa, causing acute erosion of the gastric mucosa. However, severe stress states such as severe trauma, extensive burns, sepsis, intracranial lesions, shock, and failure of vital organs are more common causes of diseases.

　　2. Pathogenesis

　　During stress states, the secretion of norepinephrine and adrenal cortical hormones increases, visceral vessels constrict, gastric blood flow decreases, and H+ cannot be cleared by reverse diffusion. Hypoxia and norepinephrine reduce the synthesis of prostaglandins, insufficient mucus secretion, and reduced secretion of HCO3-. Gastrointestinal motility is slow during stress states, the pyloric function is disordered, leading to bile reflux, and bile salts further damage the ischemic gastric mucosal epithelium, causing the gastric mucosal barrier to be damaged, ultimately leading to erosion and bleeding of the mucosa. Lesions are often seen in the fundus and body of the stomach, sometimes involving the antrum, with multiple erosions of the gastric mucosa, accompanied by pinpoint hemorrhages, and sometimes shallow small ulcers covered with white or yellow fur. Histological examination shows focal desquamation of the superficial epithelial cells at the erosion site, and the glands are twisted due to edema and hemorrhage, with infiltration of neutrophils and monocytes in the lamina propria.

　　If the treatment for acute erosive gastritis is not timely or inappropriate, it may lead to some complications, such as some patients presenting with acute massive hemorrhage. If the hemorrhage is severe, it may suddenly vomit blood. Severe cases may have symptoms such as dizziness, palpitations, dizziness, profuse sweating, and even shock. The condition is severe, and even with massive blood transfusion, the hemoglobin content is difficult to increase rapidly. A few patients with the disease caused by burns may only have an increased heart rate and decreased blood pressure due to hypovolemia.

　　Patients with a history of taking nonsteroidal anti-inflammatory analgesics, alcohol abuse, burns, major surgery, craniocerebral trauma, and failure of important organs, among other stress states, often present with pain or severe pain in the upper abdomen, accompanied by symptoms such as nausea. Those caused by drugs are also known as drug-induced gastritis. In a few patients, due to the severity of the primary disease symptoms, gastrointestinal symptoms such as dull pain or discomfort in the upper abdomen and burning sensation are often overlooked or without obvious symptoms. Hemorrhage is often the first symptom, manifested as hematemesis and/or black stools. Hemorrhage is often intermittent, and some patients may present with acute massive hemorrhage, with severe conditions, which may lead to hemorrhagic shock. Some patients with the disease caused by burns only have an increased heart rate and decreased blood pressure due to hypovolemia.

　　1, Antacids

　　Antacids such as aluminum hydroxide, magnesium hydroxide, basic bismuth carbonate (subcarbonate of bismuth) are administered through a nasogastric tube at a rate of one per hour to maintain the gastric pH above 3.5, which can effectively prevent gastric mucosal bleeding. Hastings randomly divided 100 critically ill patients into groups and gave them antacids and placebos, with 2 cases of bleeding in 51 patients who received antacid treatment, and 12 cases of bleeding in the control group of 49.

　　2, H2 receptor antagonists

　　Intravenous administration of H2 receptor antagonists is as effective as acid reducers in preventing acute gastric mucosal lesions in stressful states. Dammann reported that ranitidine 50mg/6h and famotidine 20mg/12h can effectively maintain the gastric pH above 4.

　　3, Sucralfate

　　Sucralfate has a mucosal protective effect, can counteract the damaging effects of pepsin, and can promote the release of endogenous prostaglandins. Sucralfate 1g can be taken orally every 6 hours.

　　1. X-ray examination

　　Gastrointestinal barium meal examination often cannot detect erosive lesions and is not suitable for patients with acute active bleeding because barium can coat the mucosal surface, making it impossible to perform endoscopy or angiography in the near future; in acute hemorrhage, superselective mesenteric angiography can make a localization diagnosis of hemorrhage, and it is often negative during hemorrhage intermission.

　　2. Emergency endoscopic examination

　　Emergency endoscopic examination within 24～48 hours after bleeding can reveal acute gastric mucosal lesions characterized by multiple erosions and bleeding foci, which has diagnostic value.

　　1. Drink plenty of water to supplement the loss of water and salt due to vomiting and diarrhea. The specific method is to drink alternatingly with warm dilute salt water (boiled water, coarse salt), dilute black tea water, and cooked vegetable water. Generally, 1 time per hour, 150-200 milliliters each time. Drinking plenty of water is also beneficial for the excretion of toxins.

　　After the patient stops vomiting and the frequency of diarrhea decreases, drink a small amount of millet congee or diluted lotus root starch, and then gradually eat some congee, cooked thin noodles, thin noodles, etc. Continue to drink plenty of water, and do not eat meat, eggs, and other foods rich in protein and fat, or foods that are easy to cause bloating and have a lot of dietary fiber, such as milk should not be consumed temporarily.

　　After the condition improves, for example, when the pain stops, the frequency of bowel movements decreases, and the body temperature approaches normal, one can start eating egg soup, steamed egg custard, yogurt, congee, soup, soda crackers, dried bread, steamed or braised fresh fish, minced lean meat, tender green leaves, etc. The amount of food per meal should be small.

　　During the convalescent period, it is advisable to eat easily digestible, low刺激性, and light-bloating foods, and try to make them soft and light.

　　First, treatment

　　1. General treatment

　　Eliminate the predisposing factors and treat the primary disease. Patients should rest in bed, avoid food or liquid diet, maintain tranquility, and give appropriate sedatives such as diazepam when restless; for patients with significant bleeding, maintain an open airway, and provide oxygen when necessary; strengthen nursing care, closely observe changes in consciousness, respiration, pulse, blood pressure, and bleeding, and record the intake and output for 24 hours.

　　2. Mucosal protective drugs

　　For patients without significant bleeding, mucosal protective drugs can be used, such as suspension of aluminum hydroxide and magnesium trisilicate, 2 packets, taken orally, 3～4 times a day; aluminum hydroxide magnesium trisilicate tablets, 3 tablets, taken orally, 3～4 times a day. In recent years, tegoprostil capsules (trade name: Shiveishu) have been widely used, 50mg, taken orally, 3 times a day; or misoprostol (misoprostol, trade name: Xikekui), a derivative of prostaglandin E2, commonly used at a dose of 200μg, taken 4 times a day, before meals and before bedtime; colloidal bismuth subgluconate, gatifloxacin, or compound glutamine (Maizilin-S) granules, etc., can also be used as mucosal protective drugs.

　　3. H2 receptor antagonists

　　Mild cases can be treated with oral H2 receptor antagonists, such as cimetidine 1.0～1.2g/d, taken four times a day; ranitidine 300mg/d, taken twice a day; famotidine 40mg/d, taken twice a day, or intravenous infusion for severe cases. H2 receptor antagonists can effectively inhibit the secretion of gastric acid, reduce H+ backdiffusion, and pay attention to the side effects of H2 receptor antagonists during use.

　　4, Proton pump inhibitors

　　Generally speaking, its acid-suppressing effect is stronger than that of H2 receptor antagonists. For mild cases, oral preparations can be selected, such as omeprazole 20-40mg/d, lansoprazole 30-60mg/d, pantoprazole 40mg/d. In recent years, preparations with stronger acid-suppressing effects have been applied in clinical practice, mainly rebamiprazole (rebaprazole, trade name: Politec) 10-20mg/d, because of its pharmacokinetic characteristics, it belongs to non-enzyme metabolism (i.e., not fully dependent on the metabolism of cytochrome P450 isoenzyme CYP2C19 in liver cells), so its acid-suppressing effect has no significant individual variability; esomeprazole (esomeprazole, trade name: Nexium), 20-40mg/d, taken orally, which is the levorotatory isomer of omeprazole.

　　5, Patients with massive hemorrhage

　　It is necessary to actively adopt the following treatment measures

　　(1) Blood volume expansion: For patients with massive upper gastrointestinal bleeding, it is necessary to establish a venous channel immediately, actively rehydrate, and consider the amount of fresh blood transfusion to quickly correct shock and electrolyte disturbance. The initial fluid infusion should be fast, and can choose normal saline, Ringer's solution, dextran 40 (low molecular weight dextran), etc., the fluid volume depending on the amount of blood loss, but dextran 40 (low molecular weight dextran) should not exceed 1000ml in 24 hours. Indications for blood transfusion are:

　　① Hemoglobin < 70g/L, red blood cell count < 3×10^12/L or hematocrit

　　② Systolic blood pressure

　　③ Heart rate > 140 times/min.

　　(2) Local hemostasis: Placing a gastric tube can observe the bleeding situation, judge the therapeutic effect, reduce the pressure in the stomach, and also inject drugs through the gastric tube for hemostasis.

　　① Noradrenaline: Add 6-8mg to 100ml of normal saline, take orally or intermittent infusion in the stomach.

　　② Thrombin: Dilute 1000-4000U with water, take orally or inject through a gastric tube in divided doses.

　　③ Yunnan Baiyao: Dissolve 0.5g in water and take orally, 3 times a day.

　　④ Ice saline: Inject 3-5℃ ice saline, about 500ml each time, rinse repeatedly until the rinse liquid is clear, the total amount not exceeding 3000ml, which can clear the blood in the stomach, cause the submucosal blood vessels to contract, and is beneficial to hemostasis.

　　(3) Hemostatic drugs:

　　① Carbazochrome (Anagrelide): It can reduce the permeability of capillaries and increase the retraction effect of the ends of broken capillaries, with 10mg intramuscularly every 4-8 hours.

　　② Ethamsylate (hemostatic sens): It can promote the release of platelet coagulation activity substances and increase their aggregation activity and adhesion, and can be infused by adding 2-4g to 5% glucose solution or normal saline.

　　③ Also, consider using drugs such as batroxobin, aminocaproic acid, and p-aminobenzoic acid (antifibrinolytic acid).

　　(4) Antisecretory drugs: Antisecretory drugs can reduce the secretion of gastric acid, prevent the reverse diffusion of H+, and after the pH rises, can make pepsin lose its activity, which is beneficial to the formation of blood clots and achieve the purpose of indirect hemostasis.

　　① H2 receptor antagonists: Such as cimetidine 600-1200mg each time, 1-2 times a day; famotidine 20-40mg each time, 1-2 times a day, added to glucose or normal saline for intravenous infusion.

　　② Proton pump inhibitors: Omeprazole intravenous infusion 40mg, 1-2 times a day; pantoprazole 40mg intravenous infusion, 1-2 times a day.

　　(5) Somatostatin: Artificially synthesized somatostatin has the effect of reducing the secretion of stomach acid and pepsin and visceral blood flow. O曲肽 (8 peptide, sandostatin, Xianning) is commonly used, the initial dose is 100μg, subcutaneous or intravenous injection, then maintained intravenously at a speed of 20-50μg/h for 24-48 hours; somatostatin (14 peptide, somatostatin), the initial dose is 250μg intravenous injection, then continuously infused intravenously at a speed of 250μg/h, the dose can be doubled if necessary.

　　(6) Endoscopic hemostasis: 5%-10% Mension's solution 30-50ml or norepinephrine, thrombin can be locally sprayed for hemostasis, and electrocoagulation, laser, microwave coagulation hemostasis can also be selected according to circumstances. Endoscopic hemostasis methods can be used when conventional hemostatic methods are ineffective.

　　(7) Selective arterial infusion of posterior pituitary extract: Radiotherapy can be considered when conventional hemostatic methods are ineffective. The method is to puncture the femoral artery and insert a catheter, infuse posterior pituitary extract into the celiac artery and superior mesenteric artery, 0.1-0.3U every 5 minutes, for 18-24 hours. In recent years, terlipressin is often used for infusion, 1-2mg each time, with better efficacy and fewer side effects.

　　(8) Surgical Treatment: Simple extensive erosive and hemorrhagic gastritis is not suitable for surgical treatment. For a few patients with stress ulcer hemorrhage, if bleeding is still difficult to control after 24-48 hours of active treatment in the department of internal medicine, surgical treatment can be considered after the diagnosis is basically clear based on emergency gastroscopy. Preoperative preparation should be sufficient, and sufficient blood volume should be supplemented.

　　II. Prognosis

　　For the cause, remove the triggering factors, reduce the acidity in the stomach to reduce the reverse diffusion of H, and take various hemostatic measures. For a few patients who still find it difficult to control bleeding after 24-hour active treatment in the department of internal medicine, surgical treatment can be considered. The prognosis of the patients is good.