Prolapse Gastropathy Syndrome - Causes, Symptoms, and Treatment.

Introduction

Prolapse gastropathy syndrome (PGS) occurs after forceful retching and emesis. It is a rare clinical syndrome where patients usually present with abdominal pain with or without hematemesis.

What Is Prolapse Gastropathy Syndrome?

Prolapse gastropathy syndrome (PGS) occurs after forceful retching (also called dry heaving, where the body tries to throw up without vomitus) and emesis. It is a rare clinical syndrome where patients usually present with abdominal pain with or without hematemesis (vomiting blood). It is caused when the gastric mucosa invaginates(or moves into) the lower esophageal sphincter. PGS has been considered one of the many causes of upper gastrointestinal bleeding. It can also cause chronic bleeding in patients with hiatal herniation (when the upper part of the stomach pushes through the diaphragm muscle), and recurrent retching can cause gastric and esophageal tears. The stomach fundus to the left of the esophageal lumen is the most commonly involved area. Very rarely, after invaginating repeatedly, the gastric mucosa can become hemorrhagic, resulting in bleeding in the upper GI tract.

What Is the History of Prolapse Gastropathy Syndrome?

The term prolapse gastropathy syndrome’ was proposed by Shepherd H.A in 1984. He reported 22 patients with epigastric pain alone or hematemesis with a previous history of early morning or post-prandial retching. His diagnostic criteria were persistent and recurrent retching symptoms, hematemesis, and abdominal pain. The endoscopic findings reveal prolapse of tense, inflamed, congested gastric mucosa into the esophageal lumen during retching and an unusually strong gag and retching during the endoscopy. Besides the above conditions, gastric acid is thought to be regurgitating into the esophagus and prolapsed gastric mucosa.

What Are the Causes of Prolapse Gastropathy Syndrome?

Prolapse gastropathy syndrome (PGS) develops following a forceful gag and emesis. It is caused when the gastric mucosa prolapses into the lower esophageal sphincter. There are no studies showing the association between pathologic gastric acid reflux and prolapse gastropathy syndrome, though some consider it a cause for the condition. The exact etiology of the condition is not known. Factors thought to precipitate the condition include:

• Gastroenteritis (inflammation of the stomach and intestines).

• Uremia (associated with renal abnormalities).

• Alcohol consumption.

• Pregnancy emesis (especially in the first trimester).

• Overuse of NSAIDs(Non-steroidal anti-inflammatory drugs)

• Hyperemesis gravidarum (extreme vomiting during pregnancy).

• Malignancy(cancerous conditions).

• Duodenal ulcers(duodenum is a part of the stomach).

What Are the Signs And Symptoms of Prolapse Gastropathy Syndrome?

The symptoms of prolapse gastropathy syndrome may vary from person to person. The commonly presented signs and symptoms include:

• Nausea.

• Vomiting.

• Diarrhea.

• Cramps.

• Abdominal pain.

• Loss of appetite.

• Weight loss.

• Heartburn.

• Fullness before meals.

• Gas.

• Indigestion

• Bloating.

• Acid reflux.

• Food regurgitation.

• Chest pain.

How Is Prolapse Gastropathy Syndrome Diagnosed?

The beginning diagnosis commences with a thorough case history. Details about the history of similar episodes, dietary considerations, etc., must be noted.

• Endoscopy: This is the most commonly used tool for prolapsed gastropathy. It is an outpatient procedure and uses a small flexible camera. The procedure might take about 45 minutes and require anesthesia. The camera is inserted through the mouth and can be used to visualize the entire esophagus, stomach, and duodenum. On endoscopic examination, it is seen as a well-demarcated area of congested and erythematous gastric mucosa, commonly found near the gastro-esophageal (GE) junction, surrounded by normal mucosa. Tears may or may not be evident. A portion of the gastric mucosa might forcefully prolapse retroactively through the GE junction into the esophagus during retching. Usually, there are no other abnormal endoscopic findings.

• Esophagogram (Barium Swallow): It is an imaging technique using a special type of X-ray called fluoroscopy. It shows the organs moving in real time. The person undergoing this procedure is made to drink a chalky fluid containing barium. The presence of barium in the blood enables us to see the internal organs more clearly.

• Biopsy: A biopsy of the affected area would show inflammation.

How Is Prolapse Gastropathy Syndrome Treated?

The main idea behind the treatment of prolapse gastropathy syndrome is to eradicate the underlying cause of retching and vomiting. Antiemetics can be used as an interim measure. Most cases of this condition are found to be self-limiting.

1. Lifestyle Modifications; Certain small changes can help reduce the recurrence of prolapse gastropathy.

• Avoid using over-the-counter drugs.

• Reduce intake of spicy foods.

• Avoid junk food and other foods with high amounts of fats.

• Reduce daily salt intake.

• Avoid or limit smoking.

• Reduce or quit alcohol consumption.

• Drink more water; increase your fluid intake.

• Add more probiotic foods to the diet.

• Avoid dairy products.

• Smaller meals consumed more frequently throughout the day.

2. Medications: Medications are given depending on the severity of the condition. Some medications help the underlying conditions, while others aim to relieve the symptoms. Medications given include:

• Antacids: Antacids are over-the-counter drugs used to neutralize gastric acid. They work by reducing or stopping the secretion of gastric acid.

• Proton-Pump Inhibitors(PPIs): PPIs cause a prolonged reduction in acid secretion in the stomach.

• Antibiotics: Antibiotics prevent the growth and destroy the harmful bacteria in the body

• Cytoprotective Agents: They are used to protect the lining of the stomach.

• Medications to stimulate stomach muscles.

• Antiemetics: Drugs used to prevent vomiting.

3. Blood Transfusions: The need for blood transfusions is rare. Scenarios like duodenal ulcers might require a blood transfusion.

4. Surgery: Sometimes, a surgical repair might be necessary.

Conclusion

Prolapse gastropathy syndrome is likely under-reported as it is a self-limiting condition. However, it is important to recognize the condition, as it is one of the causes of hematemesis. It is characterized by recurrent retching, causing mucosal invagination into the lower esophageal sphincter. It is usually presented as abdominal pain and, in some cases, with hematemesis. It is usually aggravated by precipitating factors like gastroenteritis, uremia, alcohol intoxication, extreme vomiting in pregnancy. An endoscopic examination may reveal a hyperemic area distal to the GE junction.

Prolapse gastropathy should be recognized as it can cause hematemesis, resulting in anemia due to blood loss and hypovolemic shock. Most cases of prolapse gastropathy would resolve on their own when the precipitating factors are removed. Hence, it would rarely require any emergency treatment. However, in cases of stomach pain, a feeling of fullness, bloating, or gassiness that persist for a few days, it is always advisable to visit a physician