What is the appropriate management for a patient with chronic abdominal pain, constipation, erosive gastritis, erosive duodenitis, and possible gastroparesis, with a history of vitamin deficiencies and no known comorbidities?

Management of Chronic Abdominal Pain with Erosive Gastritis, Erosive Duodenitis, and Possible Gastroparesis

This patient requires H. pylori testing and eradication therapy as the first priority, followed by proton pump inhibitor therapy for erosive gastritis/duodenitis, aggressive management of constipation with osmotic and stimulant laxatives, and correction of vitamin deficiencies that may be contributing to dysmotility. 1, 2

Immediate Priorities

H. pylori Testing and Eradication

• Test for H. pylori immediately using 13C-urea breath test or stool antigen test, as 100% of patients with erosive duodenitis are H. pylori positive in published series 1
• If positive, prescribe triple therapy: omeprazole 20 mg twice daily + clarithromycin 500 mg twice daily + amoxicillin 1 g twice daily for 7-14 days 1
• H. pylori eradication achieves erosion healing in 86% of cases versus only 37% without eradication (odds ratio 10 for healing) 1
• Confirm eradication with repeat breath test 4-6 weeks after completing antibiotics 1

Proton Pump Inhibitor Therapy

• Continue omeprazole 20 mg twice daily (split dosing AM and PM) for 8 weeks minimum for erosive gastritis and duodenitis 3, 4
• Split twice-daily dosing produces superior healing rates compared to once-daily dosing for erosive disease 4
• PPIs heal erosive duodenitis in >90% of patients after 4-6 weeks 5
• After healing confirmed, consider maintenance therapy with once-daily PPI to prevent relapse 5

Constipation Management

First-Line Laxative Therapy

• Start with osmotic laxative: polyethylene glycol (macrogol) daily, which sequesters fluid in the bowel without causing electrolyte disturbances 2
• Avoid magnesium salts as first-line given existing vitamin deficiencies and potential for further electrolyte depletion 2
• If inadequate response after 1-2 weeks, add stimulant laxative: senna 15-30 mg at bedtime 2
• Stimulant laxatives (senna) stimulate the myenteric plexus in the colon and are safe for long-term use despite historical concerns 2

Second-Line Prokinetic Therapy

• If laxatives fail after 4 weeks, add prucalopride (5HT4 receptor agonist) 2 mg once daily, which has prokinetic properties and is licensed for chronic constipation 2
• Alternative: linaclotide 290 mcg once daily on empty stomach, which stimulates chloride secretion and accelerates intestinal transit 2, 6
• Linaclotide also provides visceral analgesic activity for abdominal pain in IBS-C, with 34% achieving combined pain and bowel movement response versus 14-21% with placebo 6

Critical Pitfall to Avoid

• Do not use metoclopramide long-term due to risk of irreversible tardive dyskinesia and extrapyramidal effects 7
• Avoid prokinetics if patient develops evidence of mechanical obstruction 7

Abdominal Pain Management

Antispasmodic Therapy

• For colicky left-sided abdominal pain, prescribe hyoscine butylbromide (Buscopan) 10-20 mg three times daily or as needed 7, 2
• Peppermint oil 187 mg three times daily before meals is an alternative antispasmodic 2

Neuromodulator Therapy if Pain Persists

• If pain continues despite above measures, start low-dose tricyclic antidepressant: amitriptyline 10 mg at bedtime, titrate by 10 mg weekly to 25-50 mg as tolerated 2
• TCAs modulate central pain processing and have evidence for visceral pain in disorders of gut-brain interaction 2
• Avoid opioids entirely for chronic gastrointestinal pain in disorders of gut-brain interaction due to risk of narcotic bowel syndrome and worsening dysmotility 2

Vitamin Deficiency Correction

Aggressive Repletion

• Vitamin D: prescribe cholecalciferol 50,000 IU weekly for 8 weeks, then 1,000-2,000 IU daily maintenance 2
• Vitamin B12: if deficiency confirmed, give cyanocobalamin 1,000 mcg intramuscularly weekly for 4 weeks, then monthly 2
• Check and correct fat-soluble vitamins A and E, as deficiencies are common with chronic gastritis and PPI use 2
• Monitor magnesium levels and replace if low, as deficiency is common and can worsen dysmotility 2
• Consider DEXA scan to assess bone mineral density given vitamin D deficiency and chronic PPI use 2

PPI-Related Vitamin Considerations

• Long-term PPI use (>3 years) causes vitamin B12 malabsorption through hypochlorhydria 3
• Monitor B12 levels annually while on chronic PPI therapy 3

Gastroparesis Evaluation and Management

Dietary Modifications

• Recommend frequent small meals (5-6 per day) with low-fat, low-fiber content 2
• Liquid nutritional supplements are better tolerated than solid meals when gastric motility is impaired 2
• Avoid large volume meals that worsen gastric distension 2

If Gastroparesis Confirmed

• Consider gastric emptying study only if symptoms persist despite above measures 2
• Liquid feeds may be tolerated when solids are not, as gastric motility is less deranged for liquids 2

Follow-Up Strategy

Short-Term (4-8 Weeks)

• Repeat endoscopy at 8 weeks to confirm healing of erosive gastritis and duodenitis 1
• Confirm H. pylori eradication with breath test 4-6 weeks post-treatment 1
• Assess response to constipation management and adjust laxatives accordingly 2

Long-Term (3-6 Months)

• If erosions persist despite H. pylori eradication, continue PPI therapy and reassess at 6 months 1
• Monitor vitamin levels (B12, D, magnesium) every 6-12 months on chronic PPI therapy 2, 3
• Taper PPI to lowest effective dose once healing confirmed to minimize long-term risks 3

Red Flags Requiring Urgent Reassessment

• Development of severe, persistent vomiting suggesting mechanical obstruction 7
• Hematemesis or melena indicating active bleeding 8
• Unintentional weight loss >5% suggesting malnutrition requiring nutritional support 2
• Worsening abdominal distension or inability to pass flatus suggesting bowel obstruction 7