Approaching a Patient with Acute Gastritis + Uncontrolled Blood Sugar - Intern's Guide

Step 1: Introduce Yourself and Do a Quick Look (General Assessment)

• Is the patient in pain or distress?
• Is he/she conscious and oriented?
• Any signs of shock - pale, sweating, fast breathing, cold hands?
• Are there any IV lines, monitors, or catheters already in place?

Step 2: Take a Focused History (Ask Simple Questions)

For the Gastritis:

• When did the stomach pain/epigastric discomfort start?
• Any nausea, vomiting (note: vomiting raises blood sugar further and causes dehydration)
• Any blood in vomit (hematemesis) or black tarry stools (melena)? - This is a red flag
• Took any NSAIDs, aspirin, alcohol, steroids recently? (All common triggers of gastritis)
• Any history of H. pylori infection or peptic ulcer disease?
• Did symptoms start suddenly or gradually?

For Uncontrolled Sugar:

• Is the patient a known diabetic? Type 1 or Type 2?
• What medications are they on - oral hypoglycemics or insulin?
• Did they skip meals due to vomiting? (Risk of hypoglycemia if on insulin/sulphonylurea)
• Any symptoms of hyperglycemia - excessive thirst, frequent urination, blurred vision?
• Any recent illness, infection, or surgery that could have triggered the sugar spike? (Stress hyperglycemia is common)

Step 3: Physical Examination

Vitals First (Always):

• BP, Pulse, Temperature, RR, SpO2 - Note any fever (suggests infection/phlegmonous gastritis), hypotension (sepsis/bleeding)
• Blood Sugar - Check bedside glucose right away

Abdomen:

• Epigastric tenderness - classic in gastritis (press gently above the umbilicus)
• Any guarding or rigidity? (suggests perforation - emergency)
• Bowel sounds - present or absent?
• Check for hepatosplenomegaly

General:

• Signs of dehydration - dry mouth, sunken eyes, poor skin turgor (worsened by vomiting)
• Signs of peripheral neuropathy or diabetic foot (common in uncontrolled DM)
• Look for Kussmaul's breathing (deep rapid breathing - seen in DKA)
• Check urine for ketones if sugar is very high

Step 4: Investigations to Order

Urgent / Bedside:

Blood Tests:

Other:

• ECG if age > 40 or chest discomfort (MI can present as epigastric pain)
• Endoscopy - not done urgently unless bleeding is suspected; planned after stabilization

Step 5: Management (Practical Orders)

For Gastritis:

• NPO (nil by mouth) initially if vomiting - then shift to bland diet
• IV fluids - Normal saline (NS) to correct dehydration, but watch if patient has cardiac/renal issues
• IV/oral PPI - Pantoprazole 40 mg IV once or twice daily (reduces acid, promotes mucosal healing)
• Antacids (liquid Gelusil/Digene) for symptomatic relief
• Antiemetics - Ondansetron 4 mg IV or Metoclopramide for nausea/vomiting
• Stop NSAIDs, aspirin if the patient is on them - or switch to a safer alternative
• If H. pylori confirmed: Triple therapy (PPI + Amoxicillin + Clarithromycin for 14 days)
• If phlegmonous/emphysematous gastritis suspected (rare, but diabetics are at risk): Broad-spectrum IV antibiotics + surgical consult

For Uncontrolled Sugar:

• Monitor blood sugar 4-6 hourly (or hourly if very high)
• IV fluid correction - Normal saline (not dextrose initially if hyperglycemic)
• Insulin - Regular insulin sliding scale or basal-bolus regimen (as per consultant's advice)
• Check potassium before insulin - correct hypokalemia first
• Watch for hypoglycemia - especially if patient is vomiting and not eating
• If DKA suspected: Follow DKA protocol - IV fluids, insulin infusion, electrolyte replacement
• If just stress hyperglycemia: sugar often corrects when the acute illness is treated
• Inform senior/diabetologist - do not adjust insulin/OHAs independently as an intern

Step 6: Monitoring (Very Important)

Step 7: Important Red Flags - Escalate Immediately

• Hematemesis (blood in vomit) or melena (tarry black stools)
• Blood sugar > 400 mg/dL or ketones positive (possible DKA)
• Patient becomes confused, drowsy, or unresponsive
• Fever + abdominal rigidity (suggests peritonitis/phlegmonous gastritis - surgical emergency)
• Blood pressure drops (shock)
• Urine output falls

Key Concept to Remember

• Illness (gastritis, pain, infection) raises blood sugar through stress hormones (cortisol, glucagon)
• High blood sugar impairs immunity, worsens mucosal healing, and increases infection risk
• Diabetic patients are especially prone to a rare but dangerous form called emphysematous gastritis (gas-producing organisms infecting the stomach wall, as documented in Sleisenger & Fordtran's GI and Liver Disease)

Quick Summary Card for Interns

PATIENT: Acute Gastritis + Uncontrolled DM

1. Check vitals + RBS immediately
2. Examine abdomen, look for red flags
3. Order: CBC, RFT, electrolytes, HbA1c, ABG if DKA suspected
4. IV fluids (NS), IV PPI, antiemetics
5. Monitor sugar 4-6 hourly, correct with insulin per protocol
6. Stop NSAIDs; treat H. pylori if confirmed
7. Escalate: bleeding, DKA, peritonitis, confusion

• IV fluids (NS for dehydration)
• IV Pantoprazole 40 mg
• Ondansetron for vomiting
• Monitor sugar every 4-6 hrs, correct with insulin per protocol
• Check electrolytes before starting insulin

• If > 300 with vomiting - start IV Normal Saline fast, check for ketones
• If ketones positive - that's DKA, call anyone you can (even the on-call MO)

• IV NS (fluids for dehydration - always safe)
• IV Pantoprazole 40 mg OD
• IV Ondansetron 4 mg for vomiting
• NPO if vomiting badly

• Blood in vomit
• Patient is confused or unconscious
• Sugar > 400 or ketones ++
• BP dropping

• Colic - hollow organ cramping (gut, ureter, bile duct)
• Inflammation - organ is inflamed (appendix, gallbladder, pancreas)
• Ischemia - organ not getting blood (mesenteric ischemia - very bad)

• Where? Since when? Sharp or dull? Constant or comes and goes?
• Vomiting? Fever? Last time they passed stool/gas?
• Any similar episodes before?

• Press each quadrant - find where it hurts most
• Rigidity + rebound tenderness = peritonitis = surgical emergency, call surgery NOW

• Vitals, IV access
• CBC, LFT, RFT, amylase, urine routine
• USG abdomen (most useful first test)
• Hold food until diagnosis is clear

• Rigid board-like abdomen
• No bowel sounds
• BP dropping
• Fever + severe pain

• Constipation - most common, ask when they last pooped
• IBS - chronic diffuse pain, no alarming signs
• Gas/bloating - crampy, comes and goes
• Anxiety/stress - real pain, no organic cause

• Diabetic gastroparesis - especially in your uncontrolled sugar patient - stomach doesn't empty properly
• Gastroenteritis - diffuse cramps + loose stools + vomiting
• Urinary tract infection - can refer as lower abdominal pain
• Dysmenorrhea - females, ask about periods
• DKA itself - diffuse abdominal pain is a known feature

• Patient is uncomfortable but talking to you normally
• Pain is in the upper abdomen, dull or burning
• Abdomen is soft when you press
• Pressing and releasing - no worsening
• Patient can move around, change position
• May feel better after antacid or vomiting

• Patient looks sick, still, scared to move
• Pain is everywhere, constant, severe
• Abdomen feels board-like, rigid on pressing
• Rebound tenderness - pain gets WORSE when you suddenly release your hand (this is the key sign)
• Patient won't let you press - guards the abdomen
• Fever, fast pulse, may look in shock
• They lie completely still - movement makes it worse

Gastritis - patient in pain but moving. Peritonitis - patient in pain and not moving at all.

First - Do THIS for ANY poisoning before anything else:

Common Poisonings:

🐀 Rat Poison (Aluminium Phosphide - most common in India)

• Smells like garlic/fish
• Causes cardiac arrhythmia, refractory shock
• No antidote - this is the deadliest one
• Management: IV fluids, Magnesium sulphate, cardiac monitoring, ICU
• DO NOT give milk or oil (increases absorption)
• Prognosis is very poor if large dose

🐜 Ant/Insecticide Repellent (Organophosphate - OP)

• Look for: excessive salivation, tears, sweating, small pupils (miosis), loose stools, bradycardia, muscle twitching
• Remember: SLUDGE - Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis
• Antidote: Atropine - give IV, keep giving until secretions dry up (mouth dry = enough atropine)
• Also give Pralidoxime (PAM) early - within 24 hrs
• Secure airway early, suction secretions

🧴 Phenol / Lysol / Acid-Alkali (Corrosive)

• Burns mouth, throat, esophagus
• Patient has burns around mouth, hoarse voice, drooling
• DO NOT induce vomiting - will burn again on the way up
• DO NOT give gastric lavage - risk of perforation
• Give water/milk to dilute (only if within minutes)
• IV fluids, pain relief, surgical/ENT consult
• Endoscopy later to assess esophageal damage

💊 Tablet Overdose (Sleeping pills / Benzodiazepines)

• Drowsy, slow breathing, low BP
• Antidote: Flumazenil (rarely used practically)
• Management: Airway, oxygen, IV fluids, monitor
• Activated charcoal if within 1-2 hrs of ingestion

🌿 Organochlorine / DDT type

• Seizures, tremors, confusion
• No specific antidote
• Manage seizures with diazepam
• Gastric lavage if early + airway protected

Universal Rules for ALL poisoning:

Antidote cheat sheet: