Gastric Disorders (PEARLS)

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

Gastritis	Patient will present as → a 37-year-old male with a history of daily NSAID use complaining of epigastric pain, nausea, and 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 there is 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 Erosive gastritis
Gastroparesis	Patient will present as → a 32-year-old female with a longstanding history of type 1 diabetes presents with chronic nausea, early satiety, bloating, and significant weight loss over the past six months. She reports that her symptoms are particularly worse after eating. Despite maintaining strict control of her blood sugar levels, she experiences these gastrointestinal symptoms frequently. On examination, she appears malnourished and mildly dehydrated. Abdominal examination reveals a mildly distended abdomen with minimal tenderness. A gastric emptying study is performed, showing delayed gastric emptying without any obstruction. Based on these findings, she is diagnosed with diabetic gastroparesis. Dietary modifications are initiated, and she is started on metoclopramide to facilitate gastric motility, with close monitoring for potential side effects. Gastroparesis, also called delayed gastric emptying, is a disorder that slows or stops the movement of food from the stomach to the small intestine in the absence of mechanical obstruction Common symptoms include nausea, vomiting, early satiety, feeling full long after eating a meal, bloating, and abdominal pain The most common causes are diabetes mellitus, post-surgical (e.g., vagotomy), and idiopathic Other causes include medications (e.g., opioids, anticholinergics), neurological disorders (e.g., Parkinson's disease, multiple sclerosis), and connective tissue diseases (e.g., scleroderma) DX: Gastric Emptying Study (scintigraphy) is the gold standard for diagnosis Endoscopy is performed to rule out mechanical obstructions Blood Tests to identify possible underlying conditions like diabetes or thyroid dysfunction TX: Dietary modification is considered first-line therapy in patients with mild gastroparesis Prokinetic agents such as metoclopramide enhance gastric motility and help with gastric emptying In patients who fail to respond to metoclopramide, domperidone and oral erythromycin are alternative agents Antiemetics (diphenhydramine, ondansetron) are used to control nausea and vomiting Glycemic Control is essential in diabetic patients to help manage symptoms. Devices like gastric pacemakers may be used in severe cases
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 10 mm duodenal ulcer in a patient with GI bleeding Gastric ulcer (food classically causes pain) Gastric ulcers are most commonly caused by H. pylori. It 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 Esophagogastroduodenoscopy Image of gastric ulcers in the antrum 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) Pyloric stenosis You are called to see a 6-week-old with two weeks of projectile vomiting and an olive-sized abdominal mass Patient Gender: Male Age: 6 weeks Weight: 6.2 lb./2.8 kg Signs and Symptoms 2 weeks projectile vomiting; olive-sized abdominal mass; afebrile. Click here to work through this patient case simulation. Patient will present as → a 3-week-old male infant with frequent projectile vomiting after feeding, increasing in frequency and intensity over the past week. He appears dehydrated with decreased skin turgor, and examination reveals a palpable olive-shaped mass in the right upper quadrant and visible peristaltic waves. Laboratory tests show hypochloremic, hypokalemic metabolic alkalosis. On a barium upper GI series report, the radiologist states a “string sign” is present. An abdominal ultrasound confirms hypertrophic pyloric stenosis. After fluid and electrolyte repletion, the infant successfully undergoes pyloromyotomy, resulting in the resolution of vomiting and improved feeding tolerance. 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) Pyloric stenosis as seen on ultrasound in a 6-week-old. Notice the "double track" (red arrow)
Gastrointestinal bleeding	Patient will present as → a 50-year-old male with a history of alcohol use and NSAID use for chronic knee pain. He presents with melena for the past two days and a feeling of lightheadedness upon standing. He denies any vomiting, but notes a recent decrease in appetite and weight loss. On examination, he is pale, with a heart rate of 110 bpm and blood pressure of 100/60 mmHg. Gastrointestinal (GI) bleeding can be classified as upper or lower, depending on the location of the bleeding source. It can present as hematemesis, melena, or hematochezia, depending on the location and rate of bleeding Upper GI bleeding: Originates proximal to the ligament of Treitz (esophagus, stomach, or duodenum) Lower GI bleeding: Originates distal to the ligament of Treitz (small intestine, colon, or rectum) Common causes include peptic ulcer disease, esophageal varices, gastritis, and colorectal cancer Risk factors include NSAID use, alcohol use, chronic liver disease, and a history of gastrointestinal diseases Melena (black, tarry stools) often indicates upper GI bleeding, while hematochezia (bright red blood per rectum) is more indicative of lower GI bleeding DX: Laboratory Tests: CBC to assess for anemia, coagulation profile, blood type, and screen Endoscopy: Upper endoscopy (EGD) is the first-line diagnostic tool for upper GI bleeding, and colonoscopy for lower GI bleeding Imaging: In cases where endoscopy is not conclusive, angiography or capsule endoscopy may be used TX: Stabilization: Initial management includes fluid resuscitation with IV fluids and blood transfusions as needed Pharmacologic: Proton pump inhibitors (PPIs) are used in upper GI bleeding, especially with peptic ulcer disease Endoscopic Therapy: Techniques such as banding, sclerotherapy, or clipping may be used to control bleeding Surgery: Reserved for cases where endoscopic treatment is unsuccessful or not feasible

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.
	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. Play Video + Quiz
>	Midepigastric pain can be due to pancreatitis, aortic dissection, peptic ulcer disease, and myocardial infarction. Play Video + Quiz
	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. Play Video + Quiz