What are some etiologies of gastroparesis?
- Diabetes mellitus
- Medications - a2 agonists, TCAs, CCBs, octreotide
- Post-surgical - injury to vagus nerve, e.g. fundoplications, Roux-en-Y
- Neurologic disease, e.g. Parkinson
What are the clinical manifestations of gastroparesis?
- nausea (93%)
- vomiting (68 - 84%)
- abdominal pain (46 - 90%)
- early satiety (60 - 86%)
- postprandial fullness, bloating
- in severe cases, weight loss
What is the workup for suspected gastroparesis?
1. Rule out mechanical obstruction: Upper endoscopy, CT, MRI
2. Assess gastric motility: gastric emptying scintigraphy, wireless motility capsule
What is the initial treatment approach for gastroparesis?
1. Dietary modification:
- Fats and fiber move more slowly through the GI tract - eat diet low in fat and only soluble fiber
- Avoid carbonated beverages, alcohol, smoking
2. Hydration and nutrition - repeated vomiting may lead to electrolyte imbalance and/or dehydration
3. Optimize glycemic control
4. Prokinetics - metoclopramide, erythromycin
What is the treatment approach to refractory gastroparesis?
1. Jejunostomy for nutrition
2. PEG for decompression of upper GI tract
3. TCAs, gastric electrical stimulation
Diagnostic criteria for spontaneous bacterial peritonitis:
1. presence of ascites (no ascites, no SBP)
2. Polymorphonuclear cell count in ascitic fluid > 250
3. Positive culture of ascitic fluid (but don't wait for results to start treatment - if above are true, start empiric therapy)
Spontaneous bacterial peritonitis almost exclusively occurs in patients with _____.
What are the clinical manifestations of spontaneous bacterial peritonitis?
- Abdominal pain & tenderness
- Altered mental status
- Paralytic ileus, hypotension, hypothermia
How is spontaneous bacterial peritonitis treated?
1. Empiric antibiotics: IV third-generation cephalosporin -> cefotaxime, ceftriaxone
2. Albumin 1.5 g/kg IV reduces mortality
What are the complications of spontaneous bacterial peritonitis?
SBP *is* the complication - of cirrhosis! It's bad news - 40-70% mortality
What are the 4 main etiologies of ascites?
1. Portal hypertension (e.g. cirrhosis, HF)
2. Hypoalbuminemia (e.g. nephrotic syndrome, severe malnutrition)
3. Peritoneal disease (e.g. ovarian cancer)
4. Other (e.g. myxedema, disrupted pancreatic duct)
What are the clinical manifestations of ascites?
- abdominal discomfort
- shortness of breath
- early satiety
- weight gain
What is the diagnostic workup for ascites?
1. Physical exam
3. Paracentesis to determine cause of ascites
How is the cause of ascites determined?
Assessing the ascitic fluid:
- appearance - cloudy, bloody, etc.
- serum-to-ascites albumin gradient (SAAG) determination
- cell count and differential
- total protein concentration
Plus basically every single test available for serum: glucose, LDH, gram stain, triglycerides, etc.
What is SAAG and what is it for?
Serum-ascites albumin gradient -> to help determine cause of ascites
(albumin concentration of serum) - (albumin concentration of ascitic fluid)
To use it:
HIGH difference in the two: ascites is due to portal hypertension, e.g. cirrhosis, alcoholic hepatitis, HF, Budd-Chiari syndrome
LOW difference in the two: ascites is not due to portal hypertension, e.g. pancreatitis, nephrotic syndrome
What is the biggest risk factor for gastric adenocarcinoma and gastric lymphoma?
Name 4 environmental risk factors for gastric adenocarcinoma.
~high nitrate diet
~low vitamin C
~hx pernicious anemia
~hx gastric resection
What are the s/s of gastric cancer?
- Generally asymptomatic until quite advanced
Dyspepsia, epigastric pain, anorexia, early satiety, weight loss
- Ulcerating lesions can lead to bleeding and hematemesis or melena
- Pyloric obstruction leads to postprandial vomiting
- LES obstruction leads to dysphagia
- Palpable gastric mass is NOT COMMON
Sign of metastatic spread:
Virchow node! (left supraclavicular)
~No specific lab findings other than IDA if bleeding or liver test abnormalities if hepatic metastasis
What is the diagnostic workup for suspected gastric cancer?
Upper endoscopy for all patients over 55 with new dyspepsia or in any patient with dyspepsia that fails to respond to a PPI trial
What is the management of gastric cancer?
Surgical resection is the only therapy with curative potential
What is Zollinger Ellison syndrome?
a rare cause of peptic ulcer disease
What are the s/s of Zollinger Ellison syndrome?
Over 90% of patients with ZE have peptic ulcers, and usually the symptoms are indistinguishable from other causes of PUD so ZE may go undetected for years.
What is the diagnostic workup for Zollinger Ellison syndrome and when should you do it (when do you suspect possible ZE)?
- If the patient has refractory ulcers, multiple duodenal ulcers, frequent ulcer recurrences, ulcers with diarrhea, giant ulcers, or has ulcers and is negative for H. pylori and NSAID use, then ZE screening should be done.
- The most sensitive and specific method for identifying ZE is an increased fasting serum gastrin concentration.
pH should also be measured, to rule out hypochlorhydria (increased pH, whereas it will be lower with ZE).
- When testing serum gastrin, need to withdraw H2 antagonists for 24 hours and PPIs for 6 days.
Imaging is done to determine the extent of metastasis and to determine the primary tumor site.
How is Zollinger Ellison syndrome managed?
- PPIs – control hypersecretion
- Resection of tumor
List some causes of gastritis.
- H. pylori
- Serious or life-threatening illness
What is the workup for suspected gastritis?
Upper endoscopy, biopsy
H. pylori testing
What is the treatment for gastritis?
- PPI and/or H2-receptor antagonists
- Treat H. pylori as needed
- Stop offending agents (alcohol, NSAIDs, etc.)
What are the 2 major causes of peptic ulcer disease?
2. H. pylori
What are the s/s of peptic ulcer disease?
EPIGASTRIC PAIN (80-90% of patients)
- pain is well-localized to epigastrium, is gnawing, dull, aching, and not severe
- 50% of patients get relief of pain with food or antacids and a recurrence of pain 2-4 hours later
- 67% of duodenal ulcers and 33% of gastric ulcers cause nocturnal pain that awakens the patient
- Most patients have symptomatic intervals interspersed with asymptomatic months or years
What is the diagnostic workup for peptic ulcer disease?
H. pylori testing