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Hyperemic Gastropathy: Etiology, Presentation, and Management

Definition

Hyperemic gastropathy (also called congestive gastropathy or portal hypertensive gastropathy when associated with portal hypertension) is characterized by mucosal erythema, edema, and vascular engorgement of the gastric mucosa due to increased blood flow and/or impaired venous drainage.

Etiologies

CategoryMechanismExamples
Drug-InducedTopical irritation, prostaglandin inhibition → ↓ mucosal blood flow regulationNSAIDs (aspirin, ibuprofen, naproxen), corticosteroids, bisphosphonates, potassium chloride, iron
AlcoholDirect toxicity, ↑ acid, ↓ mucus, ↓ prostaglandins, mucosal vasodilationAcute binge or chronic use
Portal HypertensionIncreased gastric venous pressure → congestion, ectatic vessels (snake-skin mosaic)Cirrhosis, portal vein thrombosis, schistosomiasis
Stress-Related Mucosal DiseaseIschemia-reperfusion, ↓ mucosal defense (critically ill, burns, trauma, sepsis)Curling's ulcer (burns), Cushing's ulcer (CNS injury)
InfectiousH. pylori (chronic active gastritis), CMV, HSV, syphilis, TBH. pylori: neutrophilic infiltration + hyperemia
Bile RefluxDetergent effect of bile acids on mucosaPost-cholecystectomy, Billroth II, duodenal ulcer

Endoscopic Appearance

  • Diffuse/Erythematous: Patchy or confluent redness, friability, edema.
  • Portal Hypertensive Gastropathy: Mosaic pattern (snake-skin), cherry-red spots, dilated venules.
  • Hemorrhagic: Petechiae, active oozing, adherent clots.

Symptoms

  • Epigastric pain/burning (often meal-related)
  • Nausea, vomiting (may be coffee-ground)
  • Early satiety, bloating
  • Hematemesis/melena (if erosions/ulcers)
  • Anemia (chronic blood loss)

Diagnosis

  • Upper Endoscopy (EGD): Gold standard; visualizes mucosa, allows biopsy.
  • Biopsy: Distinguishes etiologies (H. pylori, reactive gastropathy, neoplasia).
  • H. pylori Testing: Histology, rapid urease, PCR, stool antigen, breath test.

Management

General Measures

  • Discontinue offending agents (NSAIDs, alcohol).
  • Acid suppression: PPI (omeprazole 20-40 mg daily) > H₂RA > antacids.
  • Mucosal protectants: Sucralfate, bismuth subsalicylate.
  • Eradicate H. pylori if present (PPI + 2 antibiotics × 14 days).

Specific Etiologies

  • Portal Hypertensive Gastropathy: Beta-blockers (propranolol) ↓ portal pressure; TIPS for refractory bleeding; endoscopic banding/glue for fundal varices.
  • Stress Prophylaxis: PPI or H₂RA in ICU (mechanical ventilation >48h, coagulopathy).
  • Bile Reflux: Ursodeoxycholic acid; baclofen (reduces TLESRs); Roux-en-Y diversion (refractory).

Follow-Up

  • Repeat endoscopy if bleeding, persistent symptoms, or dysplasia surveillance.
  • Monitor for gastric cancer (chronic atrophic gastritis, intestinal metaplasia).

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