questions 3

Gastritis

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Topic updated on 11/26/17 9:43am

Snapshot
  • A 55-year-old woman with a history of osteoarthritis comes into her primary care physician's office with a complaint of new indigestion. She notes that, for the past week or so, she has been experiencing discomfort in her upper abdomen, associated with meals. This has not affected her appetite, and she has not vomited up any blood or experienced any weight loss. She denies any heartburn symptoms or substance use. Her past medical history is noteworthy for osteoarthritis in her knees, and she says she has been taking naproxen as prescribed everyday for the past year and a half. She takes no other medications and is otherwise relatively healthy. (Acute gastritis)
Introduction
  • Definition
    • inflammation of the stomach
  • No universally accepted classification system
    • the updated Sydney system (1996) is most commonly used in clinical setting based on presence of nonatrophic or atrophic tissue
  • Most classification systems still distiguish by time course in order to characterize inflammatory cell infiltrate most likely present
    • acute (erosive) 
      • protective muscoal barrier is disrupted resulting in inflammation
      • represented by neutrophilic infiltration
      • a result of
        • NSAIDs
          • ↓ gastric mucosa production via  PGE2
          • consider in patients with chronic pain conditions
        • EtOH
          • common in alcoholics
        • uremia
        • burns → Curling's ulcer 
        • brain injury 
          • ↑ vagal stimulation results in ↑ H+ production
        • Anisakis worm infestation
    • chronic (nonerosive)
      • marked by mix of mononuclear cells (plasma cells, lymphocytes, macrophages)
      • there are 2 types based on location
        • Type A (fundus/body)
          • pernicious anemia is most common cause
            • associated with macrocytic anemia
            • ↓ acid production (achlorhydria) resulting in hypergastrinemia
          • also associated with other autoimmune conditions (e.g. Hashimoto's thyroiditis)
          • ↑ risk for gastric carcinoma
        • Type B (antrum/pylorus)
          • caused by infection (H. pylori, herpes, CMV)
          • also caused by chronic NSAID use
          • ↑ risk of MALT lymphoma and adenocarcinoma 
Presentation
  • Symptoms
    • recurrent upper abdominal pain
    • hematemesis (coffee ground emesis)
Evaluation
  • Endoscopy with biopsy
    • gold standard
  • H. pylori detection
    • stool antigen test
    • urease breath test
Treatment
  • Acute gastritis
    • lifestyle 
      • avoidance of gastric irritants (coffee, EtOH, NSAID, etc.)
    • pharmacologic
      • proton pump inhibitor (PPI)
      • misoprostol (synthetic PGE1)
        • contraindicated in pregnancy as it has abortifacient properties
  • Chronic gastritis
    • H. pylori treatment
      • antibiotic therapy
        • 2 stages
          • PPI + amoxicillin
          • PPI + clarithromycin + tinidazole
        • bismuth compound (Pepto-Bismol)
    • pernicious anemia treatment
      • vitamin B12
    • stress ulcer treatment
      • sucralfate, H2 blocker, PPI


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(M1.GI.122) A previously-healthy 24-year-old male is admitted to the intensive care unit following a motorcycle crash. He sustained head trauma requiring an emergency craniotomy, has burns over 30% of his body, and a fractured humerus. His pain is managed with a continuous fentanyl infusion. Two days after admission to the ICU he develops severe hematemesis. What is the mechanism underlying the development of his hematemesis? Topic Review Topic

1. Gastric mucosal disruption
2. Increased gastric acid production
3. Helicobacter pylori infection
4. Answers 1 and 2
5. Fentanyl overuse

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