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Gastritis with Severe Abdominal Pain - Medication Management

Important clinical note: "Pain throughout the abdomen" (diffuse abdominal pain) is not typical of simple gastritis alone, which usually causes epigastric/upper abdominal pain. Before adding more medications, it is important to rule out complications like peptic ulcer perforation, pancreatitis, or appendicitis - especially if the pain is severe and diffuse.

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Current Medication (Rabeprazole - Already Given)

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Medications to Add for Pain Relief

• Syrup Antacid (Aluminium hydroxide + Magnesium hydroxide, e.g., Gelusil, Digene) - 10-20 mL after meals and at bedtime
• Works within minutes by neutralising gastric acid
• Can be given alongside rabeprazole

• Dicyclomine (Dicyclomine HCl) 20 mg orally 3 times a day - reduces smooth muscle spasm
• Hyoscine butylbromide (Buscopan) 10-20 mg orally or IM - fast-acting antispasmodic, very useful for acute cramp-type pain
• Drotaverine (No-Spa) 40-80 mg orally TDS - smooth muscle relaxant, commonly used in India/Asia for gastric pain

• Ondansetron 4-8 mg orally or IV - serotonin antagonist, very effective antiemetic
• Domperidone 10 mg TDS before meals - also a prokinetic, helps gastric emptying and reduces nausea
• Metoclopramide 10 mg - alternative antiemetic/prokinetic (avoid in young patients due to extrapyramidal risk)

• Sucralfate 1 g before meals - coats and protects the gastric mucosa, useful in erosive gastritis
• Pantoprazole + Sodium Alginate combination syrups (e.g., Gaviscon) - adds a protective barrier on top of the mucosa

• Consider testing (urea breath test, stool antigen test)
• If positive: add Amoxicillin 1g + Clarithromycin 500 mg twice daily for 14 days (triple therapy with rabeprazole)

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Practical Add-On Regimen Summary

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Red Flags - When to Escalate / Investigate Further

• Diffuse/board-like rigidity of the abdomen (suggests perforation)
• Fever with severe pain (suggests infection, peritonitis)
• Sudden onset severe pain (suggests perforation or vascular cause)
• Rebound tenderness (peritoneal irritation)
• Pain radiating to back (pancreatitis - check serum amylase/lipase)
• Haematemesis or black tarry stools (upper GI bleed)
• Shock features (hypotension, tachycardia, cold extremities)

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Disclaimer: This information is for clinical guidance only. Prescribing decisions must be made by a licensed physician after physical examination and full clinical assessment of the patient. Always individualise treatment based on patient age, comorbidities, allergies, and severity of presentation.

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Acute Pancreatitis - Diagnosis & Investigations

Diagnostic Criteria (Atlanta Revised Criteria 2012)

1. Abdominal pain characteristic of acute pancreatitis - acute onset, severe, constant epigastric pain, often radiating to the mid-back
2. Serum lipase or amylase >3× upper limit of normal
3. Characteristic findings on abdominal imaging (CT/MRI/USG)

If two of the three criteria are met clinically, imaging is not mandatory for diagnosis. - Schwartz's Principles of Surgery, p. 1472

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Clinical Features

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Investigations

1. Primary Blood Tests (Most Important)

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2. Imaging

Ultrasound Abdomen (First-Line Imaging)

• Should be done in ALL patients with acute pancreatitis
• Primary purpose: identify gallstones (biliary aetiology - commonest cause)
• Can show: oedematous pancreas, peripancreatic fluid, dilated CBD
• Limitation: bowel gas often obscures pancreas in acute setting

CT Abdomen with Contrast (CECT) - Not Routine

• Not required routinely for diagnosis
• Indications for CT:
  • Diagnostic uncertainty (criteria not met)
  • Assessing complications (necrosis, abscess, pseudocyst)
  • No improvement after 48-72 hours of treatment
  • Suspected infected necrosis
• Ideally done 48-72 hours after onset (necrosis may not be apparent earlier)

• Add necrosis score (0-4) to Balthazar grade for total CTSI
• CTSI 0-3 = mild; 4-6 = moderate; 7-10 = severe

MRCP (MR Cholangiopancreatography)

• Best for evaluating bile duct and pancreatic duct anatomy
• Preferred when CBD stones or duct disruption is suspected without wanting to risk ERCP
• No radiation, no contrast nephrotoxicity

ERCP

• Diagnostic ERCP is not indicated for pancreatitis alone
• Therapeutic ERCP indicated only for: cholangitis or biliary obstruction (CBD stones not clearing)

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3. Severity Scoring Systems

Ranson's Criteria

• <3 criteria: Mild disease, low mortality (<5%)
• 3-6 criteria: Moderate-severe disease

• 6 criteria: Severe, 50% mortality risk

BISAP Score (Bedside Index for Severity in Acute Pancreatitis)

• B - BUN >25 mg/dL
• I - Impaired mental status (GCS <15)
• S - SIRS (systemic inflammatory response syndrome) present
• A - Age >60 years
• P - Pleural effusion on imaging

APACHE II Score

• Score ≥8 at 24 hours = predicted severe pancreatitis
• More complex but widely used in ICU settings

CRP

• Single simple marker: CRP >150 mg/L at 24 hours = similar accuracy to Ranson's for predicting severity

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Common Causes (to guide investigations)

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Summary: Minimum Investigation Panel for Suspected Pancreatitis

Sources: Rosen's Emergency Medicine, p.3878-3912 | Schwartz's Principles of Surgery, p.1471-1475

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ACUTE PANCREATITIS - MANAGEMENT PROTOCOL

Based on: Rosen's Emergency Medicine, Schwartz's Principles of Surgery, Current Surgical Therapy 14e, Revised Atlanta Classification 2012

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STEP 1 - SEVERITY CLASSIFICATION (First 24-48 Hours)

Revised Atlanta Classification 2012

Quick Bedside Severity: BISAP Score (within 24h)

• B - BUN >25 mg/dL
• I - Impaired mental status (GCS <15)
• S - SIRS present
• A - Age >60 years
• P - Pleural effusion on imaging

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STEP 2 - IMMEDIATE RESUSCITATION (First 6-24 Hours)

A. IV Fluid Resuscitation (Highest Priority)

• Heart rate < 120/min
• Mean arterial pressure (MAP): 65-85 mmHg
• Urine output: >0.5-1 mL/kg/h
• BUN and haematocrit trending down

Caution: Overly aggressive fluids can cause abdominal compartment syndrome, respiratory failure, and worsen sepsis. Monitor closely.

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B. Electrolyte Correction

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STEP 3 - PAIN MANAGEMENT

Pain is the cardinal symptom and its relief is a clinical priority. No single analgesic has been proven superior. (Schwartz's Principles of Surgery)

Stepwise Analgesic Approach

Morphine: Classically avoided due to theoretical sphincter of Oddi spasm. No clinical trials confirm it worsens pancreatitis, but most guidelines still recommend avoiding it when alternatives are available.

Pentazocine, meperidine, procaine HCl are also effective opioid options.

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STEP 4 - NUTRITION

Old Practice vs Current Evidence

Nutrition Guidelines

Early enteral nutrition reduces: infectious complications, organ failure severity, need for surgical intervention, and mortality compared to parenteral nutrition. (Current Surgical Therapy 14e)

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STEP 5 - ANTIBIOTICS

Key Principle: Prophylactic antibiotics are NOT recommended

Antibiotic Choice for Infected Necrosis

Probiotics are contraindicated - a multicentre RCT showed more than doubled mortality with probiotics in severe pancreatitis (possible intestinal ischaemia). (Current Surgical Therapy 14e)

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STEP 6 - ENDOSCOPIC INTERVENTION (ERCP)

Indications

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STEP 7 - SURGICAL / INTERVENTIONAL MANAGEMENT

For Necrotising Pancreatitis

Drainage Options (in order of preference)

1. Endoscopic drainage (EUS-guided, e.g., cyst-gastrostomy) - least invasive, requires walled-off collection
2. Percutaneous image-guided drainage - for immature or inaccessible collections
3. Video-assisted retroperitoneal debridement (VARD) or minimally invasive surgery
4. Open necrosectomy - highest risk, last resort; mortality 75% if done in first 2 weeks

Surgical mortality: 75% if <2 weeks, 45% at 2-4 weeks, 8% if >30 days from onset. Always delay if clinically possible. (Current Surgical Therapy 14e)

Cholecystectomy (for Gallstone Pancreatitis)

• Mild disease: Laparoscopic cholecystectomy before discharge or within 2-4 weeks (same admission preferred)
• Severe disease: Delay cholecystectomy; perform after full recovery

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STEP 8 - MONITORING

Parameters to Track

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STEP 9 - ICU ADMISSION CRITERIA

• Persistent organ failure >48h (respiratory: PaO₂ <60 / renal: creatinine >170 / cardiovascular: BP <90 despite fluids)
• BISAP score ≥3 or Ranson score ≥3
• APACHE II score ≥8
• Necrotising pancreatitis on CT
• Ongoing haemodynamic instability despite resuscitation
• Need for vasopressors

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SUMMARY FLOWCHART

Suspected Acute Pancreatitis
         |
Confirm: ≥2 of 3 criteria (pain + lipase/amylase >3x ULN + imaging)
         |
     SEVERITY?
    /         \
  MILD        MODERATELY SEVERE / SEVERE
   |                    |
Oral diet        IV LR fluid resuscitation
Early oral        (5-10 mL/kg/h → 1.5-3 mL/kg/h)
feeding          Pain control (Paracetamol → Opioids)
Monitor          Antiemetics
Discharge        NPO only if vomiting severely → NG/NJ feed
when              |
tolerated    Monitor BUN/Hct/UO/HR/MAP
              |
         BILIARY CAUSE?        INFECTED NECROSIS?
              |                       |
         ERCP if                Carbapenems + delay
         cholangitis/           intervention to ≥4 weeks
         obstruction            (percutaneous drain if deteriorating)
              |
         Cholecystectomy
         before discharge

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DRUGS SUMMARY TABLE

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Sources: Rosen's Emergency Medicine (9th Ed), pp. 3874-3900 | Schwartz's Principles of Surgery (11th Ed), pp. 1471-1475 | Current Surgical Therapy (14th Ed) | Revised Atlanta Classification 2012 (Banks et al., Gut)

Disclaimer: This protocol is a clinical reference guide. All treatment decisions must be individualised based on the patient's clinical state, comorbidities, local institutional guidelines, and physician judgement.