Acute/Chronic Gastritis

Acute gastritis: inflammation of gastric mucosa (immune cells without erosion)

Chronic, acute gastritis ➔ peptic ulcer disease, cancer (adenocarcinoma)

H. pylori (MCC acute/chronic gastritis)

  • Acute gastritis ➔ chronic acute gastritis ➔ dyspepsia

  • Causes ulcers and infection is carcinogenic

  • ↑ risk of MALToma (mucosa-associated lymphoid tissue lymphoma) and adenocarcinoma

  • H. pylori uses urease to cleave urea ➔ NH3 (basic) ➔ ↑ stomach pH

H. pylori DX:

  • If pt has SX (other than dyspepsia) that warrant EGD (EGD is not indicated solely for H. pylori DX)

    • EGD with biopsy (from antrum)

    • Gram negative rods; intraepithelial neutrophils and plasma cells in lamina propria (trying to attack infxn)

      • Plasma cell proliferation ➔ ↑ risk of MALToma

  • If pt only has dyspepsia:

    • Urea breath test: For initial dx (test affected by PPI/bismuth/ABX use, and active ulcer bleeding)

    • Stool antigen testing: Best for confirming eradication

    • Serology: If never infected/tx before (can be positive in pts with active or prior infection)

H. pylori TX:

  • Triple therapy: Clarithomycin AND amoxicillin (or metronidazole) AND PPI

Pernicious anemia

  • Antibodies targeting parietal cells ➔ ↓ intrinsic factor and ↓ HCl

  • Pt may have hx of auto-immune dz

    • ↓ Intrinsic factor ➔ B12 deficiency ➔ macrocytic anemia (MMA positive ➔ neuro sx)

    • ↓ HCl ➔ ↑ gastrin ➔ ↑ risk of carcinoid tumor

    • Chronic acute gastritis ➔ ↑ risk of adenocarcinoma

Pernicious anemia DX:

  • Anti-parietal cell, anti-intrinsic factor, anti-H/K ATPase

  • EGD with biopsy shows gastric atrophy with achlorhydria

Pernicious anemia TX:

  • Requires lifelong parenteral B12 (IM): 1mg Q weekly x 1mo, then 1mg Q 1mo

Peptic Ulcer Disease

Ulcer

  • Defect through gastric or duodenal mucosa, muscularis mucosae, and into submucosa

Acute stress ulcers

  • Require PPX (feeding > PPI/H2 blocker)

    • ICU pt (on pressors/hypotensive)

    • Cushings ulcer: ↑ ICP (from bleed or tumor)

    • Curlings ulcer: Burn pt

PUD

  • One or more ulcers in stomach or duodenum

    • H. pylori (MCC) ➔ duodenal ulcer > gastric ulcer

      • ⊣ gastrin secretion ➔ ↑H+, ⊣ HCO3 secretion

    • NSAIDs ⊣ COX 1 & COX 2 ➔ ↓ prostaglandins (prostaglandins protect gastric mucosa)

      • ↑ risk of PUD and impaired healing: poor diet, stress, etOH, tobacco, steroid use, caffeine

    • Zollinger Ellison (gastrinoma) ➔ ↑ gastrin secretion ➔ ↑ HCl secretion (duodenal ulcer MC)

    • CMV, radiation, cocaine, Chron

Ulcer SSX:

  • Many are ASX, epigastric pain (MC), dyspepsia

    • Classic duodenal ulcer

        • Relief with food (buffers acid)

        • ↑ pain ~2-4hrs after eating (no more food buffer)

        • Nocturnal pain (late night/early morning ➔ ↑ acid secretion)

    • Classic gastric ulcer

      • ↑ pain immediately after eating

  • BOLO:

    • Upper GI bleed ➔ hematemesis, melena, (↑ bleeding ➔ hematochezia, orthostatic)

    • Perforation ➔ sudden onset ABD pain, tachy, rigidity

    • Penetration of bowel wall ➔ fistulas

    • Gastric outlet obstruction (least common complication)

Ulcer DX:

  • BUN:Cr >30:1 or >100:1 (GI bleeding ➔ ↑ nitrogenous waste ➔ ↑ BUN without ↑ Cr)

  • EGD with biopsy

Ulcer TX:

  • Eradicate H. pylori (triple therapy)

  • Stop NSAIDs

  • PPIs (omeprazole)

    • Complicated (bleeding, perforation, gastric outlet obstruction) ➔ IV til pt tolerates PO (4-12wks)

    • Uncomplicated ~2wks

  • Continued PPIs: >2cm, ulcers not from H. pylori/NSAIDs, failed eradication, or have to continue using NSAIDs

Zollinger Ellison

  • Gastrinoma: neuroendocrine tumor (MC in duodenum or pancreas) secretes gastrin

  • Benign BUT can ➔ malignancy

  • MC in ♂ and associated with MEN1

ZE SSX:

  • Ulcers refractory to BID PPIs

  • ↑ ↑ H+ ➔ diarrhea

  • ⊣ pancreas ➔ steatorrhea and malabsorption

ZE DX:

  • ↑ serum gastrin >1,000 (10x normal) and pH <2

  • If gastrin <10x normal and pH >2: Secretin stimulation test

    • PPIs affect gastrin levels but should not be stopped if ZE expected (can ➔ acute bleed/perf)

    • So, EGD to check for active ulcers and switch to H2 blockers one week before SST

  • Somatostatin receptor-based imaging to localize tumor

ZE TX:

  • Resection

Gastric outlet obstruction

Causes:

  • Malignancy MCC

  • Peptic ulcers

  • Pancreatitis

  • IBD

  • Intramural hematoma s/p ABD trauma

  • Bezoar (accumulation of inorganic/organic material) - hair

SSX:

  • Epigastric pain ➔ vomiting

  • Early satiety, distension

  • Succussion splash (low sensitivity): Pt rocked back-forth at hips, auscultate splash of retained gastric material (>3hrs s/p meal)

DX:

  • Imaging shows distention with retained material in gastric lumen

  • Upper endoscopy shows luminal obstruction and identifies material

TX:

  • TX as obstruction (NPO, NGT, IVF) + PPIs

  • Bezoars

    • Mild sx: Can try cocacola lavage, prokinetics (metoclopramide) BOLO for SBO in 4-6wks

    • Severe or refractory to chemical dissolution: endoscopic removal

Gastroparesis

  • Delayed gastric emptying

  • MCC idiopathic

  • Associated with DM (T1 >T2)

    • Autonomic neuropathy

    • Hyperglycemia ➔ slowed gastric emtpying

  • Opioids, CCB, GLP-1 agnoists

  • POSTOP

SSX:

  • ABD pain with eating

  • N/V (± food ingested hours earlier)

  • Early satiety, distension

  • Peripheral neuropathy in pts with DM

DX:

  • R/O mechanical obstruction with EGD and CT

  • Emptying study (scintigraphic gastric emptying) with radio-tracer egg-white meal

    • Gastric retention >60% at 2hrs AND/OR >10% at 4hrs

TX:

  • Avoid things that slow gastric emptying and glucose control

  • Prokinetics: metoclopramide (PO), eryhromycin (IV) for acute flare