HEMORRHAGIC GASTRITIS
HEMORRHAGIC GASTRITIS, the most frequent cause of upper gastrointestinal tract bleeding among cancer patients, is characterized by two distinctly different clinical presentations. Of 82 adult cancer patients treated at the Sloan-Kettering Institute between 1971 and 1975, 35% had exogenous or "stress" ulcers. A combination of stress risk factors and gastric irritants were present in 30% of patients, while the remaining 35% were bleeding from ingested irritants alone.' The most common malignancy associated with endogenous gastric ulcers was lymphoma or leukemia, followed by gastrointestinal, genitourinary, gynecologic, breast and lung cancers.
Ulcerations of endogenous origin were usually seen in patients with sepsis, recent major surgery or multiple organ failure, while those of exogenous origin were associated with ingestion of gastric irritants such as aspirin or alcohol. The latter group were treated by discontinuing the offending agent and the liberal use of antacids. Few if any blood transfusions were necessary, and most patients stopped bleeding in less than 24 hours. Surgical intervention was not required. In contrast, bleeding of endogenous origin was prolonged and associated with a mortality of 47%, although death was moire often due to multiple organ decompensation than continued blood loss. Patients in the stress group required an average of 15 units of blood during the course of bleeding, which averaged 8 days in duration. Their mortality rose to 63% if gastric irritants were also ingested. The primary cause of mortality was sepsis in 29%, gastric bleeding in 29%, hepatic failure in 16%, myocardial infarction in 10%, advanced tumor in 6.5%, respiratory failure in 6.5% and uremia in 3% of the 82 patients. Most of them had 2 or more of these complications at the same time.
Treatment of hemorrhagic gastritis associated with multiple orgafl failure and sepsis requires all the resources of a sophisticated, multidisciplinary critical care unit. Early endoscopic or angiographic confirmation followed by intensive organ support, control of sepsis, withdrawal of offending.irritants, correction of any coexisting coagulopathy and adequate blood, fresh frozen plasma and platelet transfusion were the important principles of treatment. Endoscopy in these 82 patients revealed ulcerations in the distal antrum with exogenous irritants, while involvement of the proximal part of the stomach was more typical of endogenous stress factors. The entire gastric mucosa was diffusely ulcerated