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Snapshot
  • A 55-year-old man presents to his primary care physician for intermittent epigastric pain for the past few months. He reports having sudden-onset nausea and bloating episodes as well. His other past medical history includes chronic back pain, for which he takes ibuprofen regularly. He smokes cigarettes and drinks alcohol on a daily basis. He is prescribed a proton pump inhibitor, instructed to cut back on alcohol, and scheduled for an upper endoscopy.  
Introduction
  • Overview
    • inflammation of the gastric mucosa often with erosive changes
    • subtypes are
      • acute gastritis
        • due to NSAID use, alcohol, severe illness, or H. pylori infection 
      • chronic gastritis
        • atrophic gastritis
          • due to autoantibodies to gastric parietal cells
        • nonatrophic gastritis
          • due to NSAID use, alcohol, or other factors
  • Epidemiology
    • demographics
      • adults
      • chronic gastritis is very common
    • risk factors
      • east Asian heritage
      • drug use
      • prior history of H. pylori
      • autoimmune disease
  • Pathogenesis
    • mechanism
      • atrophic gastritis
        • loss of parietal cells
        • atrophy of gastric mucosa
      • nonatrophic gastritis
        • inflammation of gastric mucosa
  • Associated conditions
    • atrophic gastritis
      • other autoimmune diseases i.e., pernicious anemia and diabetes mellitus
Presentation
  • History
    • may be asymptomatic
    • sudden-onset nausea
    • vomiting
    • hematemesis
    • melena
    • bloating
  • Symptoms
    • common symptoms
      • location
        • epigastric pain
      • aggravating factor
        • NSAID use
        • alcohol use
  • Physical exam
    • palpation
      • may have epigastric tenderness
Imaging
  • No imaging indicated
Studies
  • Serum labs
    • normal gastrin level
    • vitamin B12 may be decreased in atrophic gastritis
    • H. pylori antibody testing
      • does not distinguish between current or past infection
  • Invasive studies
    • endoscopy
      • indications
        • all patients
        • most accurate test
      • findings
        • inflammation of gastric mucosa
        • erosions
        • ulcers
    • urease breath test
      • indication
        • test for H. pylori
        • used to diagnose and confirm eradication of the infection
    • H. pylori stool antigen test
      • indication
        • test for H. pylori
        • used to diagnose and confirm eradication of the infection
  • Histology
    • biopsy from endoscopy
      • findings
        • atrophy
        • chronic inflammation
        • intestinal metaplasia
Differential
  • Zollinger-Ellison syndrome
    • key distinguishing factors
      • symptoms of gastritis that aren’t responsive to therapy
      • elevated serum gastrin levels
Treatment
  • Nonoperative
    • lifestyle changes
      • avoid exacerbating agents
        • indication
          • all patients
    • proton-pump inhibitors or H2 blockers
      • indication
        • all patients except those with atrophic gastritis
        • prophylaxis for patients at risk for stress ulcers
          • head trauma
          • intubation
          • burns
          • coagulopathy
    • H. pylori eradication therapy
      • indication
        • H. pylori positive disease
      • modalities
        • triple therapy
          • proton pump inhibitor
          • clarithromycin
          • amoxicillin or metronidazole
        • quadruple therapy
          • proton pump inhibitor
          • bismuth subcitrate
          • metronidazole
          • tetracycline
    • vitamin B12 supplementation
      • indication
        • atrophic gastritis
Complications
  • Gastric cancer
  • Gastrointestinal bleeding
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.73) A 35-year-old woman returns to her primary care physician for follow up after treatment for a peptic ulcer. She was diagnosed with a duodenal ulcer and gastritis; endoscopy and biopsy with Warthin Starry staining at the time of diagnosis showed the following (Figure A). She has completed a course with amoxicillin, clindamycin, and omeprazole. The patient reports resolution of symptoms. What is the next best step in management for this patient? Review Topic

QID: 106564
FIGURES:
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Discontinue antibiotics, but continue proton pump inhibitor

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2

Schedule an endoscopy to biopsy duodenal ulcer

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3

Evaluate serum IgG and IgA against H. pylori

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4

Perform a urease breath test

67%

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Discontinue therapy, as the patient has completed triple therapy and is not asymptomatic

11%

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(M2.GI.4694) A 38-year-old man presents to his gastroenterologist after being referred by his primary care physician (PCP). He has had intractable epigastric pain for the last 3 months following meals. His PCP prescribed him a course of ranitidine. After his symptoms did not resolve he was prescribed omeprazole. However, his symptoms persisted and he was referred to gastroenterology. The man undergoes an endoscopy, which finds a gastric ulcer (Figure A). Biopsy with silver staining is shown in Figure B. Which of the following is the most effective regimen for the treatment of this condition? Review Topic

QID: 107883
FIGURES:
1

Omeprazole, metronidazole, tetracycline, bismuth

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2

Omeprazole, penicillin, ranitidine

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3

Amoxicillin, clarithromycin

0%

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4

Pantoprazole

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Pantoprazole and levofloxacin

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