Stomach Stuff

Gastritis, Peptic Ulcer Disease, Pyloric Stenosis, Neoplasms

Gastritis

Inflammation, infection, or damage to the stomach’s mucosal lining

Nonerosive, Erosive/hemorrhagic, infectious disease states

Categories of Gastritis

Nonerosive Gastritis

Gastric irritation and atrophy caused by cellular changes or weakened host mechanisms

Pernicious anemia, H. plyori (body)

Types of Nonerosive gastritis

Pernicious anemia

An autoimmune condition resulting in B12 malabsorption due to decreased intrinsic factor (loss of parietal cells - antibody mediated 70%)

Parenteral B12, PPI

Treatment plan for Pernicious Anemia related Gastritis gastritis

H. plyori

A Gram neg bacillus that secretes ammonia as a buffer to gastric acid and is spread via oral-oral or fecal-oral

Family hx of ulcers, similar symptoms, or H. plyori

Risk factors for H.plyori

Fecal antigen immunoassay (sens/spec 95%), Urea breath test (sens/spec 95%), Serological ELISA

Patient presents to the ER for abdominal pain for the last 3 days. She states that is so mad she doesn’t want to eat and also reports N/V. On a physical exam you note mid-epigastric tenderness. Family Hx is positive for PUD. What labs do you want?

No PPI for 7 days, Abx for 28

What are the rules for running fecal and breath test for H. plyori

Actively bleeding ulcer, recent PPI/abx use, endoscopic abnormality requiring biopsy, or failure of other treatment

When should you get a upper endoscopy on a patient with possible H.plyori (sen 90%/spec 95%)?

14 days (at least 7) of PPI, Clarithromycin, Amoxicillin (metro for PCN allergy), test for eradication in 4 weeks; Preferred treatment is the Bismuth Quad

Patient presents to the ER for abdominal pain for the last 3 days. She states that is so mad she doesn’t want to eat and also reports N/V. On a physical exam you note mid-epigastric tenderness. Family Hx is positive for PUD. Urea breath test and fecal antigen testing are consistent with H. plyori, what is the game plan team?

Erosive/Hemorrhagic gastritis

Gastric mucosal erosion due to inhibition of normal mucosal defenses allowing gastric fluids to damage tissues OR local damage from ingested items

Meds (NSAIDs), H. Plyori (Antrum), EtOH, Stress, Portal HTN, Consumed irritants (takis ☹ )

Common causes of erosive/hemorrhagic gastritis

Chronic NSAID usage, severe medical illness/injury, chronic/binge drinking, family hx, liver disease, spicy/acidic foods

Risk factors for erosive/hemorrhagic gastritis

Upper endoscopy (#1 draft pick), CBC (anemia if chronic), urea breath test, fecal antigen test, fecal occult blood

Patient presents to the ER for abdominal pain. He reports that he has loss his appetite as well as nausea. He also reports that his stools have been dark and tarry. On a physical exam you mote mid-epigastic tenderness and a coffee ground blood on NG suction. What diagnostics do you want?

Continuous PPI infusion, PO sucralfate suspension, possible endoscopic repair

Patient presents to the ER for abdominal pain. He reports that he has loss his appetite as well as nausea. He also reports that his stools have been dark and tarry. On a physical exam you mote mid-epigastic tenderness and a coffee ground blood on NG suction. Upper endoscopy is positive for erosive gastritis, let’s say stress induced, what is your treatment plan?

PPI PO/IV prophylactically

How can we avoid stress-induced erosive gastritis in our severely ill/injured peeps?

Stop the NSAID (or drop the dose) switch to COX2 inhibitors (celecoxib), educate patients to take meds with food, Begin PPI for 2-4 weeks (if no improvement endoscopy)

Patient presents to the ER for abdominal pain. He reports that he has loss his appetite as well as nausea. He also reports that his stools have been dark and tarry. On a physical exam you mote mid-epigastic tenderness and a coffee ground blood on NG suction. Upper endoscopy is positive for erosive gastritis, let’s say NSAID induced, what is your treatment plan?

Stop eating hot chip and lie, Stop alcohol, Start PPI/H2/sucralfate for 2-4 weeks

Patient presents to the ER for abdominal pain. He reports that he has loss his appetite as well as nausea. He also reports that his stools have been dark and tarry. On a physical exam you mote mid-epigastic tenderness and a coffee ground blood on NG suction. Upper endoscopy is positive for erosive gastritis, let’s say EtOH and Takis induced, what is your treatment plan?

Propanolol, Treat liver disease, PPI/sucralfate for symptomatic relief

Patient presents to the ER for abdominal pain. He reports that he has loss his appetite as well as nausea. He also reports that his stools have been dark and tarry. On a physical exam you mote mid-epigastic tenderness and a coffee ground blood on NG suction. Upper endoscopy is positive for erosive gastritis, let’s say portal hypertension, what is your treatment plan?

PUD, GERD, cancer, biliary tract disease, Viral/bacterial gastroenteritis (stomach bug, food poisoning), Cardiac, aortic aneurysm

Differentials for Gastritis

Peptic Ulcer Disease (PUD)

The destruction of the gastric or duodenal mucosa by digestive factors such as acid or pepsin due to impaired/overwhelmed mucosal defense mechanisms

muscularis mucosae, 5mm+

Ulcers extend through the ______________________ and are usually ______ in diameter

duodenum

Peptic ulcers are more commonly (5x) found in the…

NSAID usage, H. Pylori infections (most common)

What causes peptic ulcer disease (90% of ‘em)

reduces the natural protective barrier

What is the mechanism behind H.pylori and PUD?

COX-1 inhibition leads to impaired mucosal defenses

What is the mechanism behind NSAIDs and PUD?

Living with family members with H.plyori, Long-term NSAID usage

PUD risk factors

urea breath test, fecal antigen testing, CBC (Anemia), digital rectal (fecal occult blood), Abdominal Xray

Patient presents to the ER for SEVERE abdominal pain that he describes as gnawing. He said that it has gotten so bad he can’t even sleep, but does get better when he has a midnight snack. You note mid-epigastric tenderness, a rigid abdomen with guarding and positive peritoneal signs. What diagnostics do you want?

Standard triple therapy (PPI, Clarithromycin, Amoxicillin); Preferred is Bismuth Quad

Patient presents to the ER for SEVERE abdominal pain that he describes as gnawing. He said that it has gotten so bad he can’t even sleep, but does get better when he has a midnight snack. You note mid-epigastric tenderness, a rigid abdomen with guarding and positive peritoneal signs. Fecal antigen and urea breath testing are both positive for H. pylori. See CXR. What is your treatment plan?

Stop the NSAID, switch to COX-2, Start PPRI for 4-6 weeks, Start broad spectrum abx for the perforation

Patient presents to the ER for SEVERE abdominal pain that he describes as gnawing. He said that it has gotten so bad he can’t even sleep, but does get better when he has a midnight snack. PMHx is positive for back pain for which he is prescribed 800 mg ibuprofen PRN. You note mid-epigastric tenderness, a rigid abdomen with guarding and positive peritoneal signs. Fecal antigen and urea breath testing are both negative for H. pylori. See CXR. What is your treatment plan?

Onset after 50, progressive dysphagia, odynophagia, recurrent vomiting, Sx despite treatment, Postive FOBT, melena, blood in emesis, anemia, Severe abdominal pain, weight loss, FHx of FI cancer in 1st degree

Upper endoscopy is the definitive diagnostic for PUD but is only require IF

gastritis, GERD, Cancer, Billiary tract disease, gastroenteritis

PUD DDx

Pyloric Stenosis

An acquired condition caused by hypertrophy and spasm of the pyloric sphincter resulting in gastric outlet obstruction - occurs in 0.6-0.8% of live birth but can be adult acquired

Male (5x)

Risk factors for Pyloric stenosis, more commonly occur in the first, familial hx, exposure to macrolides

chronic gastritis, Chronic PUD, gastric cancers, Chronic gallbladder disease (Bourveret’s syndrome)

Risk factors for secondary plyoric stenosis

Bouveret’s Syndrome

A rare complication of a bilio-digestive fistula, where a big stone occludes the pyloric-duodenal region

CMP (Cl, bicarb, elevated BUN), Xray, U/S (radiologic test of choice), Barium Swallow study

4 day old baby returns to the ER for failure to thrive. Mother reports the the baby has been projectile vomiting after every feeding and that after the baby eats, “you can see the stomach move”. On a physical exam you note an ability to palpate an olive and dry mucous membranes. What diagnostics you want?

Stabilize (Big IVs, fluids), Surgical pyloromyotomy (definitive), post-op ad lib feeding improves prognosis

4 day old baby returns to the ER for failure to thrive. Mother reports the the baby has been projectile vomiting after every feeding and that after the baby eats, “you can see the stomach move”. On a physical exam you note an ability to palpate an olive and dry mucous membranes. Labs show metabolic alkalosis, hypochloremia, elevated BUN. Xray shows dilated stomach with no gas in the intestines. U/S shows a elongated and thickened pyloris with at target sign. Swallow study shows a string sign. What is your treatment plan

adenocarcinoma, lymphoma, carcinoid tumor

Types of gastric neoplasms

Intestinal (resemble glandular structures), Diffuse (poorly differentiated)

Cellular variants of gastric adenocarcinoma

Chronic H. pylori, Pernicious anemia, smoking, nitrates, salts, low vitamin C, FHx of gastric cancer (consider gastectomy)

Risk factors for Gastric Adenocarcinoma

Upper endoscopy with biopsy, CBC, LFTs, Fecal occult blood

77 y/o male presents to the clinic for heartburn. He also reports symptoms of anorexia and states that “I must not need to eat as much, I get full with like 2 bites.” On physical exam you note midepisgastric tenderness, weightloss, and pallor. What diagnostics?

CT (chest, abdomen, pelvis), Endoscopic U/S

77 y/o male presents to the clinic for heartburn. He also reports symptoms of anorexia and states that “I must not need to eat as much, I get full with like 2 bites.” On physical exam you note midepigastric tenderness, weight loss, and pallor. Initial diagnostics show gastric adenocarcinoma what other test do you want to look at the extension of the cancer?

Surgical resection (laproscopic or open), perioperative chemo, palliative surg/chemo for non curative

Treatment plan for gastric adenocarcinoma

Gastric lymphoma

What is the second most common type of gastric cancer and H. pylori is the largest risk factors?

Upper endoscopy, Fecal occult blood, CBC, LFTs, lymph node biopsy, H. pylori labs

OG Diagnostics for Gastric lymphoma

CT (chest, abdomen, pelvis), bone marrow biopsy

Diagnostics for Gastric lymphoma after the OGs

Treat H. Pylori, radiation and chemo

Treatment plan for gastric lymphoma

Gastric carcinoid tumors

Which is the rarest form of Gastric cancer but most (75%) occur with pernicious anemia?

Skin flushing with hypotension, telangiectasias, diarrhea, bronchospasm

Carcinoid syndrome is characterized by

endoscopy with biopsy

Diagnostic of choice for gastric cancers in general

resection (small, local, single), Radial gastrectomy with regional lymphadenectomy (localized multiple)

Treatment plan for gastric carcinoid tumors

Peptic ulcers, gastritis, GERD, other intra-abdominal tumors, bowel/colon cancers

DDx for gastric neoplasms