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

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

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

• 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