PANCE Blueprint GI and Nutrition (9%)

Gastric Disorders (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint covers three topics under the category of gastric disorders

Patient will present as → a 37-year-old male with a history of daily NSAID use complaining of epigastric pain, nausea, vomiting, all worsened by eating. On physical examination, he is tender to palpation in the epigastrium. He admits to drinking approximately two beers per day. 

Dyspepsia (belching, bloating, distension, and heartburn) and abdominal pain are common indicators of gastritis

Three causes:

1. Infection - H. pylori (most common)

  • Location: antrum and body
  • Studies: urea breath test or fecal antigen

2. Inflammation of the stomach lining (NSAIDS and Alcohol)

  • NSAIDs: cause gastric injury by diminishing local prostaglandin production in the stomach and duodenum
  • Alcohol: a leading cause of gastritis

3. Autoimmune or hypersensitivity reaction (e.g. pernicious anemia)

  • Location: Body of the fundus
  • Pernicious anemia: + schilling test ↓ intrinsic factor and parietal cell antibodies

Treatment and diagnosis: stop NSAIDs, empiric therapy with acid suppression 4-8 wks. of PPI

  • If no response, consider upper GI endoscopy with biopsy and ultrasound
  • Test for H. pylori infection → if H. pylori (+) treat with (CAP)clarithromycin + amoxicillin +/- metronidazole + PPI (i.e. Omeprazole)
  • Quadruple therapy (PPI, Pepto, and 2 antibiotics) for one week
Peptic ulcer disease
Gastric ulcer: Patient will present with → abdominal discomfort that is worse with meals and gets better an hour or so later after eating.

Duodenal ulcer: Patient will present as → a 62-year-old female with complaints of epigastric pain and belching which improves when she eats food but gets worse a few hours after her meal. She said he has noticed a change in the color of her stool.

PUD is an ulcer of the upper GI tract mucosa involving the proximal duodenum (90%) and distal stomach (10%). There are 2 main types of ulcers duodenal and gastric

Duodenal ulcer (food classically decreases pain think Duodenum = Decreased pain with food)

  • Duodenal ulcers are more than twice as common as gastric ulcers
  • Duodenal ulcers are most commonly caused by H. pylori (95%)
  • Pts typically present with epigastric pain that is better after meals

Gastric ulcer (food classically causes pain)

  • Gastric ulcers are most commonly caused by H. pylori. Can also be caused by NSAIDs, acid reflux, smoking
  • Pain is described as gnawing or burning and usually radiates to the back
  • Pts typically present with epigastric pain that is worse after meals

Bleeding — Acute upper gastrointestinal hemorrhage is the most common complication of peptic ulcer disease

DX: Upper endoscopy is the most accurate diagnostic test for peptic ulcer disease

  • Biopsy for H. pylori should be obtained in all patients undergoing upper endoscopy for PUD unless contraindicated
  • Ulcer biopsy of benign-appearing duodenal ulcers is not recommended
    • All ulcers with malignant features should be biopsied

TX: All patients with peptic ulcers should receive antisecretory therapy with a proton pump inhibitor (PPI) (eg, omeprazole 20 to 40 mg daily or equivalent) for 4-8 weeks

  • Patients with evidence of H. pylori on biopsy should receive eradication therapy
    • Treatment for H.Pylori ⇒ think baseball "CAP" = clarithromycin + amoxicillin + PPI
      • Quadruple therapy: PPI + Bismuth subsalicylate 524 mg 4 times a day + Metronidazole 250 mg 4 times a day + Tetracycline 500 mg 4 times a day
        • Best initial therapy in areas where the clarithromycin resistance rate is > 15%
    • In patients with active bleeding, a negative biopsy result does not exclude H. pylori, and a breath test or a stool antigen test for H. pylori should be performed to confirm a negative result
    • In patients who receive treatment for H. pylori, eradication should be confirmed four or more weeks after the completion of therapy
  • Discontinue nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Patients with duodenal ulcers who have been treated do not need further endoscopy unless symptoms persist at four weeks or recur
Pyloric stenosis
ReelDx Virtual Rounds (Pyloric stenosis)
Patient will present as → a 6-week-old first-born baby boy with projectile vomiting after feedings over the last 24 hours. Mom says that he enjoys feeding, and even after he vomits, he appears eager and hungry. On physical exam, you palpate an olive-shaped mass in the epigastric region at the lateral edge right upper quadrant. Labs show blood pH 7.47 and potassium of 3.2 mmol/L. On a barium upper GI series report, the radiologist states a “string sign” is present.

Pyloric stenosis is a congenital condition where a newborn’s pylorus undergoes hyperplasia and hypertrophy, leading to obstruction of the pyloric valve which causes vomiting (that might be projectile), as well as dehydration and metabolic alkalosis

Projectile vomiting occurs shortly after feeding in an infant < 3 mo. old with a palpable “olive-like” mass at the lateral edge of the right upper quadrant
  • Pediatric patients < 3 months old
  • Nonbilious projectile vomiting after most or every feeding
  • Physical exam - palpable epigastric olive-shaped mass (is pathognomonic for the disorder)

DX: Diagnosis is by ultrasound

  • On ultrasound, you will see a double-track
  • Barium studies will reveal a string sign or “shoulder sign”
  • Labs: Hypochloremic, hypokalemic metabolic alkalosis (secondary to dehydration) 

TX: surgical correction - pyloromyotomy (Ramstedt's procedure) 

Acute abdomen is a general term used to describe any patient condition that involves sudden onset and severe abdominal pain. There are many conditions that may or may not require emergent surgery to treat, which is why it is important to be able to quickly identify the cause. It can be helpful to sort the causes of acute abdomen into the classically defined region of abdominal pain. Pain can manifest in any location in cases of bowel obstruction, peritonitis, mesenteric ischemia, and strangulation.
IM_MED_Acute_Abdomen_Differential_Diagosis_Upper_Quadrants_v1.3 The causes within the right upper quadrant (RUQ) include cholecystitis, biliary colic, cholangitis, perforated duodenal ulcer, and acute hepatitis. The causes within the left upper quadrant (LUQ)  include splenic rupture and irritable bowel syndrome in conjunction with splenic flexure syndrome.

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>IM_MED_Midepigastrium_V1.3 Midepigastric pain can be due to pancreatitis, aortic dissection, peptic ulcer disease, and myocardial infarction.

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IM_MED_Acute_Abdomen_Differential_Diagosis_Lower_Quadrants_v1.2 Causes within the lower quadrants include ovarian torsion, ectopic pregnancy, pyelonephritis, renal calculi, and acute salpingitis. Appendicitis is most commonly associated with right lower quadrant (RLQ) pain, and causes within the left lower quadrant (LLQ) include sigmoid volvulus and sigmoid diverticulitis.

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