PANCE Blueprint GI and Nutrition (9%)

Gastric Disorders (PEARLS)

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

Gastritis 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 wk 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 Etiology: H. pylori (most common), NSAID use, Zollinger-Ellison syndrome (refractory PUD) - gastrin-secreting tumor

  • Duodenal ulcer- pain improves with food*
  • Gastric ulcer- pain worsens with food

Diagnosis: Endoscopy with biopsy is gold standard for diagnosis

Treatment:

  • H. pylori infection: Triple therapy PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole
  • NSAIDs use: discontinue use
  • Zollinger-Ellison syndrome: PPI and resect tumor
Pyloric stenosis 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

  • 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) 
  • Treatment: 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.

Acute Abdomen Differential Diagnosis: Upper Quadrants Picmonic

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

Acute Abdomen Differential Diagnosis: Midepigastrium and Diffuse Picmonic

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.

Acute Abdomen Differential Diagnosis: Lower Quadrants Picmonic

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