Acute erosive hemorrhagic gastritis

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

　　Some patients may present with acute massive hemorrhage, with severe illness, and it is difficult to rapidly increase the hemoglobin content despite massive blood transfusions. A few cases caused by burns may only show pulse acceleration and blood pressure drop due to low blood volume.

　　Patients with a history of taking non-steroidal anti-inflammatory analgesics, excessive alcohol consumption, burns, major surgery, craniocerebral trauma, and critical organ dysfunction, among other stress states, may experience symptoms such as obscure or severe pain in the upper abdomen, accompanied by nausea and other symptoms. In cases caused by medication, it is also known as medication-induced gastritis. A few patients may neglect or have no obvious symptoms of gastrointestinal tract before hemorrhage, such as obscure pain and burning sensation in the upper abdomen, due to severe symptoms of the primary disease. Hemorrhage is often the first symptom, manifested as hematemesis and/or melena, and hemorrhage is often intermittent. Some patients may present with acute massive hemorrhage, with severe illness and possible hemodynamic shock.

　　1. Acid-suppressing agents

　　Acid-suppressing agents such as aluminum hydroxide, magnesium hydroxide, and bismuth subcarbonate (basic bismuth carbonate) are administered via nasogastric tube at a frequency of once every hour to maintain the intragastric pH above 3.5, which can effectively prevent gastrointestinal mucosal hemorrhage. Hastings randomly divided 100 critically ill patients into two groups, one receiving acid-suppressing agents and the other receiving placebos. The results showed that among the 51 patients who received acid-suppressing agent treatment, 2 cases of hemorrhage occurred, while in the control group of 49 patients, 12 cases of hemorrhage occurred.

　　2. H2 receptor antagonists

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

　　3. Sulfasalazine

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

　　1. X-ray examination

　　Gastrointestinal barium meal examination is often unable to 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 cases of acute bleeding, superselective angiography of the superior mesenteric artery can make a localization diagnosis of bleeding; during intervals of bleeding, it is often negative.

　　2. Emergency endoscopic examination

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

　　First, for acute gastritis patients, it is advisable to consume more of the following foods:

　　1. Drink plenty of water to supplement the water and salt lost due to vomiting and diarrhea. The specific method is to alternate drinking warm dilute salt water (boiled water, coarse salt), dilute black tea water, and cooked vegetable water. Generally, once an hour, each time 150-200 milliliters. Drinking plenty of water is also beneficial for eliminating toxins.

　　2. After the patient stops vomiting and the number of diarrhea episodes decreases, opt for drinking a small amount of millet congee or diluted lotus root starch, and then gradually consume porridge, soft thin noodles, and thin noodles. Continue to drink plenty of water, and do not rush to eat foods rich in protein and fat such as meat and eggs, or foods that are prone to cause flatulence and are rich in dietary fiber, such as milk should not be consumed temporarily.

　　3. After the condition improves, for example, when abdominal pain stops, bowel movements decrease, and body temperature approaches normal, one can start eating things like egg soup, steamed egg custard, yogurt, congee, soup, soda biscuits, toasted bread, steamed or stewed fresh fish, minced lean meat, tender vegetable leaves, etc. The amount of food per meal should be small.

　　4. During the recovery period, it is advisable to eat easily digestible, low刺激性, and light gas-producing foods, and try to make them soft and light.

　　Second, foods not suitable for consumption:

　　To avoid gastrointestinal fermentation and flatulence, it is advisable to avoid eating beef and other gas-producing foods during the acute stage, and to minimize the intake of sucrose. Attention should be paid to dietary hygiene. Avoid high-fat fried, smoked, and preserved fish, vegetables and fruits with high fiber content, beverages with strong刺激性, food and seasonings, etc.

　　First, general treatment

　　Eliminate the causes of the disease and treat the primary disease. The patient should rest in bed, refrain from eating or have a liquid diet, maintain calmness, and provide appropriate sedatives such as diazepam when restless; for those 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 conditions, and record the 24-hour intake and output.

　　Two. Mucosal protective drugs

　　For patients without obvious bleeding, mucosal protective drugs such as suspension of sucralfate and oral magnesium hydroxide-aluminum carbonate can be used. In recent years, the oral capsule of teprenone has been widely used; or misoprostol, a derivative of prostaglandin E2, is taken before meals and at bedtime. Colloidal bismuth subcitrate, gatifloxacin, or compound glutamine (Mizulin-S) granules can also be selected as mucosal protective drugs.

　　Three. H2 receptor antagonists

　　For mild cases, oral H2 receptor antagonists such as cimetidine, ranitidine, and famotidine can be taken; for severe cases, intravenous drip medication can be used. H2 receptor antagonists can effectively inhibit the secretion of gastric acid, reduce the reverse diffusion of H+, and attention should be paid to the side effects of H2 receptor antagonists during use.

　　Four. Proton pump inhibitors

　　Generally speaking, its acid-suppressing effect is stronger than that of H2 receptor antagonists. For mild cases, oral preparations such as omeprazole, lansoprazole, and pantoprazole can be selected. In recent years, preparations with stronger acid-suppressing effects have been applied in clinical practice, mainly including rabeprazole, which is non-enzyme metabolism (i.e., not completely dependent on the cytochrome P450 isoenzyme CYP2C19 for metabolism) due to its pharmacokinetic characteristics, so its acid-suppressing effect has no significant individual differences; esomeprazole, which is the levorotatory isomer of omeprazole.

　　Five. For patients with massive hemorrhage, it is necessary to actively adopt the following treatment measures

　　1. For patients with upper gastrointestinal hemorrhage, it is necessary to establish a venous channel immediately, actively rehydrate, appropriately transfuse fresh blood, and quickly correct shock and electrolyte disorders. The infusion should start quickly, and physiological saline, Ringer's solution, and 40 (low molecular weight dextran) can be selected, and the fluid replacement volume is determined according to the amount of blood loss, but 40 (low molecular weight dextran) should not exceed 1000ml within 24 hours. The indications for blood transfusion are: ①Hemoglobin 140 times/minute.

　　2. Local hemostasis: Retaining a gastric tube can observe the bleeding situation, judge the therapeutic effect, reduce intragastric pressure, and also inject drugs for hemostasis through the gastric tube. ①Norepinephrine is added to 100ml of physiological saline and administered orally or intermittently infused into the stomach. ②Thrombin 1000-4000U is diluted with water and administered orally or infused through the gastric tube. ③Yunnan Baiyao 0.5g is dissolved in water and taken orally. ④Ice saline is infused with 3-5°C ice saline, about 500ml each time, repeatedly flushed until the flushing fluid 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 conducive to hemostasis.

　　3. Hemostatic drugs: ①Captopril (Anlocu) can reduce the permeability of capillaries and increase the retraction effect of the broken ends of capillaries. ②Sulfonated phenylethylamine (Hemostatic Sens) can promote the release of platelet coagulation activity substances and increase their aggregation activity and adhesion, which can be infused into the body with 5% glucose solution or physiological saline. ③It is also appropriate to select drugs such as Batroxobin, aminocaproic acid, and aminomethylbenzoic acid (antifibrinolytic acid).

　　4. Antisecretory drugs Antisecretory drugs can reduce gastric acid secretion, prevent H+ reverse diffusion, and after pH rises, the pepsin can lose its activity, which is conducive to the formation of blood clots and achieves the purpose of indirect hemostasis. ①H2 receptor antagonists such as cimetidine; famotidine, added to glucose or saline for intravenous infusion. ②Proton pump inhibitors such as omeprazole for intravenous infusion; pantoprazole 40mg for intravenous infusion.

　　5. Somatostatin Artificially synthesized somatostatin has the effect of reducing gastric acid and pepsin secretion and visceral blood flow. Commonly used octreotide (8 peptide, sandostatin, Zineta) is administered subcutaneously or intravenously, and then maintained intravenously at a rate of 20 to 50μg/h for 24 to 48 hours; somatostatin (14 peptide, somatostatin) is administered intravenously, and then maintained at a rate of 250μg/h by continuous intravenous infusion, and the dose can be doubled if necessary.

　　6. Endoscopic hemostasis can be achieved by spraying 30 to 50ml of 5% to 10% Mension's solution or norepinephrine, thrombin locally, or by electrocoagulation, laser, or microwave coagulation hemostasis according to circumstances. If conventional hemostasis methods are ineffective, endoscopic hemostasis methods can be used.

　　7. If conventional hemostasis methods are ineffective, consider applying radiological interventional treatment, which involves puncturing the femoral artery and inserting a catheter to infuse posterior pituitary hormone into the celiac artery and superior mesenteric artery, at a rate of 0.1 to 0.3U every 5 minutes, for 18 to 24 hours. In recent years, terlipressin at 1 to 2mg per infusion is often used, which has better efficacy and fewer side effects.

　　8. Surgical treatment is not recommended for the simple extensive erosive and hemorrhagic gastritis. In a few cases with stress ulcer hemorrhage, if bleeding is still uncontrollable after 24 to 48 hours of active medical treatment, and the diagnosis is basically clear after emergency gastroscopy, surgical treatment can be considered. Adequate preparation before surgery is required, and sufficient blood volume should be supplemented.