Stomach Conditions

These conditions usually present with epigastric pain. When dealing with stomach conditions you should be aware of the 5 alarm symptoms or age>55years, which require urgent upper GI endoscopy:

Anaemia

Loss of weight

Anorexia

Recent onset symptoms

Malaena/hematemesis

Acute gastritis

This refers acute inflammation of the stomach mucosa, which occurs due to anvimbalance between mucus defence and acid.

The stomach is usually lined by bicarbonate ions, prostaglandins and a mucus barrier,vwhich protects against stomach acid.

The acid damage results in superficial inflammation and can cause erosions (loss ofvsuperficial layer), which may progress to ulcer development (loss of mucosal layer).

Risk factors

Alcohol

Drugs – NSAIDs, steroids

Hiatus hernia

Symptoms

Epigastric pain or discomfort

Vomiting or heartburn

Management

Advice on avoiding alcohol, tobacco, and spicy food

Medical management involves proton-pump inhibitors and histamine antagonists

Chronic Infective Gastritis

The most common form of gastritis, usually due to the bacterium Helicobacter pylori.

This bacterium makes a urease enzyme which breaks down the mucus defence.

This destroys the protective layer and leads to chronic inflammation, which increases the risk for gastric adenocarcinoma and MALT lymphoma.

It can cause epigastric pain and lead to the development of peptic ulcers.

Symptoms

Epigastric pain

Peptic ulcer disease

Key tests

Non-invasive tests are 13C breath test (1st line), stool antigen and serology

Invasive tests are histology (from biopsy) and CLO (campylobacter-like organism) test which can be performed during an OGDpsy)

Management

Triple therapy with 2 antibiotics and proton-pump inhibitors, e.g., PPI (lansoprazole) and amoxicillin and clarithromycin or metronidazole for 7 days

If penicillin allergic, you can give clarithromycin and metronidazole

Chronic autoimmune gastritis

This occurs due to autoimmune destruction of parietal cells which line the stomach.

T cells make antibodies against parietal cells and/or intrinsic factor.

This leads to stomach atrophy. A lack of intrinsic factor can also cause vitamin B12 deficiency, which leads to pernicious anaemia.

Symptoms

Mild jaundice, diarrhoea, sore tongue

Anaemia symptoms, e.g., fatigue, light-headedness, syncope, paleness

Management

Vitamin B12 and folic acid replacement

Peptic ulcer disease

This refers to the development of a mucosal ulcer. It is usually found in the proximal duodenum (most common) or the distal part of the stomach.

Duodenal ulcers usually are not malignant, but gastric uclers are associated with gastric cancer.

Duodenal ulcer

This presents with epigastric pain that improves with meals (95% due to H. Pylori)

Usually found in the anterior duodenum.

Posterior ulcers are prone to rupture giving bleeding from gastroduodenal artery, major source of bleeding

Gastric ulcer

This presents with epigastric pain that worsens with meals, risk of bleeding from left gastric

Risk factors

Helicobacter pylori (most common cause)

Drugs – NSAIDs, SSRIs, steroids

Severe burn (Curling’s ulcer) – hypovolemia decreases blood supply to stomach

Raised intracranial pressure (Cushing’s ulcer) – increased vagal nerve stimulation leads to an increase in acid production

Zollinger-Ellison syndrome – a gastrin-secreting adenoma, which leads to increased gastric acid secretion and the formation of multiple peptic ulcers

Key tests

Upper GI endoscopy and biopsy to exclude carcinoma

Check for H. pylori using breath test or stool antigen test

Management

Correct underlying cause, high dose PPI to reduce stomach acid secretion 

Gastro-Oesophageal Reflux Disease (GORD)

This is a condition which leads to reflux of acid from the stomach into the oesophagus.

It is mostly due to reduced lower oesophageal sphincter tone (idiopathic).

It is also associated with features like obesity and drinking caffeine.

There is also an increased risk in hiatus hernia. This refers to herniation of the stomach above the diaphragm, which usually occurs in overweight patients.

H. pylori eradication is not routinely used in the treatment of GORD.

Causes

Reduced lower Oesophageal sphincter tone (idiopathic)

Obesity

Caffeine

Hiatus hernia – this is herniation of the stomach above the diaphragm, usually in overweight patients

Symptoms

Heartburn, belching (dyspepsia)

Cough, damage to enamel of teeth

Dysphagia is possible but usually no weight loss and patients are systemically well

Can lead to stricture formation and Barrett’s oesophagus (intestinal metaplasia), which increases the risk of developing oesophageal cancer

Complications

Oesophagitis with stricture

Barrett oesophagus – intestinal metaplasia giving risk of Oesophageal cancer

Key tests

Endoscopy if there are red flag (ALARM) symptoms, especially in patients over the age of 55, or for patients in which symptoms persist > 4 weeks despite treatment

If endoscopy is negative, can do 24-hour oesophageal pH monitoring

Management

Encourage weight loss, reduce acid secretion with PPIs

If symptoms persist, surgical options are explored, e.g., laparoscopic fundoplication, a surgery which prevents reflux by wrapping gastric fundus around lower oesophageal sphincter. This is considered after other options have been exhausted.

Gastric carcinoma

This is a malignant proliferation of the surface epithelial cells, which can be divided into two types. These tumours present late and metastasise to lymph nodes, e.g., Virchow’s node (Troisier sign).

Intestinal type

This is more common and presents as a large ulcer usually in antrum

It commonly metastasizes to liver and umbilicus (Giving Sister Mary Joseph Node)

Risk factors

Inflammatory conditions – H. Pylori, autoimmune gastritis

Blood group A

High nitrate diet (Japan)

Diffuse type

This is characterized by signet ring cells that infiltrate gastric wall causing diffuse thickening

Not associated with the previous risk factors

Can metastasize to ovaries (Krukenberg tumour)

MALT lymphoma

This is a gastric lymphoma which is usually due to H. pylori infection.

It can lead to a raised protein level in the blood but has a good prognosis.

It is treated by H. pylori eradication, but if persistent may require chemotherapy.

Symptoms

Weight loss and anorexia

Abdominal pain and dysphagia

Nausea and vomiting

Epigastric mass

Key tests

OGD with biopsy is the definitive investigation

Imaging, e.g., CT or endoscopic ultrasound can be used for staging

Management

Surgical resection of tumour (e.g., gastrectomy), with combination chemotherapy