History

Fact Explanation
Abdominal pain - Upper abdomen/ epigastric Inflammation with associated mucosal injury [1,2]
Anorexia Inflammation of the stomach[1,2]
Nausea Inflammation of the stomach [1,2]
Vomitting Inflammation of the stomach [1,2]
Hematemesis - Coffee ground colour Inflammation with associated mucosal injury causing bleeding [1,2]
Melena Inflammation with associated mucosal injury causing bleeding [1,2]
Symptoms of Anemia Due to Chronic blood loss or Due to anemia Resulting from Pernicious Anemia of Atrophic Gastritis [3]
Neurological symptoms - Peripheral symptoms such as numbness, disturbance of gait, ataxia Atrophic gastritis may cause Vitamin B12 deficiency [3]
Past medical histroy of NSAID use, steroid use Both NSAIDs and Corticosteroids reduce Prostaglandin production thereby reducing production of Gastric Mucus [2,4]
References
  1. PAPADAKIS MA, MCPHEE SJ, RABOW MW. CURRENT Medical Diagnosis & Treatment, 52nd Edition, New York, McGrawHill-Lange, 2013
  2. KUMAR P, CLARK M. Clinical Medicine, 8th Edition, Edinburgh, Saunders-Elsevier, 2012
  3. STABLER SP. Vitamin B12 Deficiency. The New England Journal of Medicine 2013; 368:149-160. January 10, 2013. DOI: 10.1056/NEJMcp1113996
  4. LONGO DL, FAUCI AS, KASPER DL, HAUSER SL, JAMESON JL, LASCALZO J. Harrison's principles of internal medicine, 18th edition, New York, McGrawHill-Medical, 2012

Examination

Fact Explanation
Epigastric tenderness Inflammation of the stomach [1]
Tachycardia Dehydration following vomiting [2]
Pallor Usually due to long standing blood loss from stomach
Board like rigidity and severe tenderness of abdomen Perforated peptic ulcer [2]
Succussion splash of stomach Gastric outlet obstruction due to peptic ulcer disease [2]
Pallor with mild jaundice, tachycardia, cardiomegaly and cardiac flow murmur on ausculation [3] Severe Vitamin B12 deficiency of atrophic gastritis
Neurological signs - Ataxic gait [3] Severe Vitamin B12 deficiency of atrophic gastritis
References
  1. KUMAR P, CLARK M. Clinical Medicine, 8th Edition, Edinburgh, Saunders-Elsevier, 2012
  2. LONGO DL, FAUCI AS, KASPER DL, HAUSER SL, JAMESON JL, LASCALZO J. Harrison's principles of internal medicine, 18th edition, New York, McGraw-Hill, 2012
  3. STABLER SP. Vitamin B12 Deficiency. The New England Journal of Medicine 2013; 368:149-160. January 10, 2013. DOI: 10.1056/NEJMcp1113996

Differential Diagnoses

Fact Explanation
Pancreatitis Gives rise to Epigastric pain and tenderness on examination. However pain classically radiates to back through the body. [1,2]
Cholecystitis Gives rise to upper abdominal/epigastric pain. But often colicky in nature. Pain radiates classically to the inferior angle of scapula along the chest wall. [1,2]
Myocardial Infarction May give rise to visceral type epigastric pain. however associated with other symptoms of cardiac ischemia such as palpitations, sweating, radiation of pain to upper limbs/ neck/ jaw [1,2]
Perforated peptic ulcer Silent perforation may occur in the elderly or patients on steroids [1,2]
Gastro-esophageal reflux Gastric acid can irritate the esophageal mucosa. [1,2]
Pneumonia Lower lobe pneumonia. Associated with symptoms of fever, cough, shortness of breath, chest pain [3]
Diabetic Ketoacidosis May present with upper abdominal pain. Patient will be severely dehydrated, polyuria, high blood sugar, positive urine ketones [3]
Porphyria May present with upper abdominal pain. Other neuropsychiatric symptoms will be present such as change of behavior, epilepsy, peripheral neuropathies [3]
References
  1. KUMAR P, CLARK M. Clinical Medicine, 8th Edition, Edinburgh, Saunders-Elsevier, 2012
  2. LONGO DL, FAUCI AS , KASPER DL, HAUSER SL, JAMESON JL, LOSCALZO J. Harrison's principles of internal medicine, 18th Edition, United States of America, McGraw- Hill companies Inc, 2012
  3. BALACHANDRAN B, SINGHI S, LAL S. Emergency management of acute abdomen in children. Indian Journal of Pediatrics. 2013 Mar;80(3):226-34. doi: 10.1007/s12098-013-0991-1

Investigations - for Diagnosis

Fact Explanation
Upper GI endoscopy Ability to directly visualize the gastric mucosa, and take biopsies to exclude malignant lesions. [1,2] or detect Atrophic Gastritis. [3]
Barium studies To detect peptic or duodenal ulcers[1]
Non-endoscopic investigation for helicobacter pylori: IgG antibodies for H. pylori, Urea breath test, H. pylori antigen in stool Helicobacter pylori infection commonly causes gastritis, peptic ulcer disease, duodenal ulcer disease [3]
Endoscopic investigation for helicobacter pylori: Biopsy urease test, biopsy for histology, biopsy for culture of H. pylori Helicobacter pylori infection commonly causes gastritis, peptic ulcer disease, duodenal ulcer disease [3]
Serum Gastrin level To diagnose Zollinger-Ellison syndrome [1]
References
  1. LONGO DL, FAUCI AS , KASPER DL, HAUSER SL, JAMESON JL, LOSCALZO J. Harrison's principles of internal medicine, 18th Edition, United States of America, McGraw- Hill companies Inc, 2012
  2. DU Y, BAI Y, XIE P, FANG J, WANG X, et al. Chronic gastritis in China: a national multi-center survey. BMC Gastroenterology 2014, 14:21 doi:10.1186/1471-230X-14-21
  3. McCOLL KEL. Helicobacter pylori Infection. The New England Journal of Medicine 2010; 362:1597-16 04 April 29, 2010. DOI: 10.1056/NEJMcp1001110

Investigations - Fitness for Management

Fact Explanation
Hemoglobin level Anemia due to chronic blood loss or anemia due to Atrophic gastritis causing Pernicious anemia [1]
References
  1. PAPADAKIS MA, McPHEE SJ, RABOW MW. CURRENT Medical Diagnosis & Treatment, 52nd Edition, New York, McGrawHill-Lange, 2013

Investigations - Followup

Fact Explanation
Repeat testing for H. pylori after course of anti-H. pylori treatment - Urea breath test or H pylori stool antigen test if ulcer was duodenal, endoscopy if it was gastric. To ensure H. pylori eradication and healing of gastric ulcer if present. [1]
Repeat annual upper GI endoscopy for patients with atrophic gastritis who have intestinal metaplasia on histology To screen for malignant change. [1]
References
  1. DINIS-RIBEIRO M, LOPES C, DACOSTA-PEREIRA AD, GUILHERME M, et al. A follow up model for patients with atrophic chronic gastritis and intestinal metaplasia. Journal of Clinical Pathololgy. Feb 2004; 57(2): 177–182. PubMed. doi: 10.1136/jcp.2003.11270

Investigations - Screening/Staging

Fact Explanation
Blood picture - Megaloblastic anemia with hyper segmented neutrophils. Due to atrophic gastritis causing pernicious anemia [1]
Antibodies against Intrinsic factor and gastric parietal cell To screen for atrophic gastritis and pernicious anemia [1]
References
  1. BIZZARO N, ANTICO A. Diagnosis and classification of pernicious anemia. Autoimmunity Reviews. 2014 Jan 11. pii: S1568-9972(14)00054-8. PubMed.gov. doi: 10.1016/j.autrev.2014.01.042

Management - General Measures

Fact Explanation
Proton-pump inhibitors eg; Omeprazole, Pantaprazole, Lanzaprozole Reduces gastric acid secretion [1]
H2 Blockers eg; Cimetidine, Famotidine, Ranitidine, etc Reduces gastric acid secretion[2].
Antacids Symptomatic; Neutralizes gastric acid [3]
Prokinetic drugs eg; Domperidone, Metochlopramide Increases evacuation of gastric acid from the stomach [4]
Parenteral Vitamin B12 supplementation in Atrophic gastritis Reduced production of intrinsic factor due to depleted parietal cells in atrophic gastritis. Therefore reduced absorption of Vitamin B12 from intestine.[5]
References
  1. DATTILO M, FIGURA N. Helicobacter pylori infection, chronic gastritis, and proton pump inhibitors. Journal of Clinical Gastroenterology. 1998;27 Suppl 1:S163-9. PubMed. Available from http://www.ncbi.nlm.nih.gov/pubmed/9872516
  2. BYTZER P. H2 receptor antagonists and prokinetics in dyspepsia: a critical review. Gut 2002; 50: iv58-iv62. BMJ. doi:10.1136/gut.50.suppl_4.iv58
  3. WHARTON GK. Effective medical management of peptic ulcer and gastritis. The American Journal of Digestive Diseases. September 1955, Volume 22, Issue 9, pp 262-266.
  4. ANGELINI G, CASTAGNINI A, RIZZOLI R, et al. Treatment of reflux gastritis: double blind comparison between clebopride and domperidone. A preliminary report. Italian Journal of Gastroenterology. 1990 Feb;22(1):24-7. PubMed. available from : http://www.ncbi.nlm.nih.gov/pubmed/2131924
  5. LONGO DL, FAUCI AS, KASPER DL, HAUSER SL, JAMESON JL, LASCALZO J. Harrison's principles of internal medicine, 18th edition, New York, McGrawHill-Medical, 2012

Management - Specific Treatments

Fact Explanation
Eradication of H. pylori Triple therapy regimes, e.g. Omeprazole 20mg + Clarithromycin 500mg + Amoxicillin 1g all twice daily for 14 days or Omeprazole 20mg + Clarithromycin 500mg + Metronidazole 500mg all twice daily for 14 days If peptic ulcer disease is present [1,2]
References
  1. DATTILO M, FIGURA N. Helicobacter pylori infection, chronic gastritis, and proton pump inhibitors. Journal of Clinical Gastroenterology. 1998;27 Suppl 1:S163-9. PubMed. Available from http://www.ncbi.nlm.nih.gov/pubmed/9872516
  2. KUMAR P, CLARK M. Clinical Medicine, 8th Edition, Edinburgh, Saunders-Elsevier, 2012