gastroenterology panre reviewobjectives review relevant gi a&p and topics covered on panre...

Gastroenterology

PANRE Review

Brock Phillips, PA-C

OBJECTIVES

Review relevant GI A&P and topics covered

on PANRE Blueprint - buzzwords & key

points are noted in red

Score 100% on the GI section!

Clinical pearls to enhance your skill & comfort

with GI complaints

DISCLOSURES

None - I’m a practicing PA-C in the trenches,

fresh off my own PANRE recert in 2016! If I

did it, you can too!!!

GI IS JUST PLUMBING -

IT’S NOT BRAIN SURGERY!!!

ESOPHAGUS

Esophagitis

Motility disorders

Strictures

Neoplasms

Mallory-Weiss tear

Varices

Esophagitis

Infectious vs. non-

infectious

Infectious: Candida,

HSV (shallow ulcers),

CMV (deep)

Non-infectious:

GERD, Rads/chemo,

pill-induced (NSAIDs,

bisphosphonates,

Tetra/Doxycycline)

Esophagitis

Inflammation of the esophagus

S/SX: Odyno-/dysphagia (pain/difficulty w/

swallowing), chest/substernal pain

Workup: EGD, BX

TX: Stop offending agents, address

comorbidities, Fluconazole, Magic

Mouthwash, PPI

Motility Disorders

Arise from disorders of smooth muscle or

intrinsic nervous system

Dysphagia (to liquids, solids or both) is MC

presenting complaint

Examples: Achalasia, Esophageal spasm,

Scleroderma, CVA

Achalasia

Loss of ganglion cells in Auerbach’s plexus -

increased tone, impaired relaxation of LES,

absent peristalsis

S/SX: Dysphagia to solids/liquids, regurg of

non-digested/non-acidic material

DX: “Bird’s beak” on barium swallow, EGD,

esophageal manometry

TX: Dilatation, botox, esophagomyotomy

Achalasia

Strictures

Narrowing of the esophagus

Can be anatomic or result from GERD,

esophagitis, NG tube injury

Examples: Schatzki’s ring, Zenker’s

diverticulum, Esophageal web

Schatzki’s Ring

Circumferential lower

esophageal ring, often

assoc. w/ hiatal hernia &

GERD

S/SX: Intermittent

dysphagia to solids, GERD

DX: EGD, barium swallow

TX: Dilatation

Zenker’s Diverticulum

Outpouching of

proximal esophageal

mucosa

S/SX: Dysphagia,

regurgitation, halitosis,

globus, aspiration risk

DX: EGD, barium

swallow

TX: Soft diet, surgery

Esophageal Web

Thin, found in mid-upper esophagus

Plummer-Vinson syndrome - webs assoc. w/

severe Fe deficiency. Combo of this plus

koilonychia (spoon-shaped nails), glossitis,

chelosis - also Fe def SX

TX: Fe supplement, dilatation

Mnemonic: ”The plumber Vincent DIGS a

hole for the iron pipe” (dysphagia, iron def,

glossitis, squamous cell ca risk ↑ )

Plummer-Vinson Syndrome

Esophageal Cancer

Predominantly M>F (3:1), older (50-70)

Squamous cell ca - prox 2/3 esophagus,

ETOH/smoking = risk factors

Adenocarcinoma - distal 1/3 esophagus,

Barrett’s esophagus = risk factor

Esophageal Cancer

S/SX: Progressive

dysphagia, wt loss

DX: EGD w/ BX,

endoscopic U/S,

CT

TX: Chemo/rads,

surgical resection

Barrett’s Esophagus

Complication of GERD (10% of cases) w/

chronic inflammation leading to metaplasia

40x increased risk of esophageal cancer!!!

Mallory-Weiss Tear

Superficial mucosal tear at gastroesophageal

junction due to vomiting/retching

S/SX: Painless hematemesis

TX: Usually self-limiting, EGD w/ thermal

coagulation or epi

…not to be confused with…

Boerhaave’s Syndrome

Esophageal rupture due to forceful vomiting,

instrumentation (s/p EGD)

S/SX: Tearing pain & hematemesis, crepitus,

“Hamman’s crunch” on auscultation

DX: Mediastinal widening on CXR, CT

TX: Surgical consult STAT, ABX, antiemetics,

Esophageal Varices

Dilated submucosal veins in lower esophagus

due to cirrhosis, portal HTN

30% w/ varices bleed - 30% of those will die,

bleeding is often recurrent

S/SX: UGIB w/ brisk BR hematemesis, +/-

melena, +/- hypoTN & instability

TX: IVF, blood, octreotide, EGD

banding/sclerotherapy

STOMACH

GERD

Gastritis

Peptic Ulcer Disease

Neoplasms

Pyloric Stenosis

Gastroesophageal Reflux Dz

Decreased LES tone leading to reflux of

gastric contents into esophagus

S/SX: Heartburn, regurgitation, chest pain,

chronic cough, laryngitis

DX: Clinical

TX: Antacid/H2/PPI, weight/diet/lifestyle,

surgical fundoplication

Can lead to reflux esophagitis, strictures,

Barrett’s esophagus

Gastritis

Inflammation of

stomach lining

(ETOH, NSAIDs, H.

pylori, stress/illness)

S/SX: Dyspepsia,

upper abd pain, N/V

DX: EGD w/ BX, H.

pylori testing

TX: Like GERD

Peptic Ulcer Disease

Ulceration resulting from

imbalance between

aggressive/defensive

factors of gastroduodenal

mucosa

Caused by H. pylori,

NSAIDs, secretory issues

Duodenal 5x more

common than gastric

Peptic Ulcer Disease

S/SX: “Gnawing, burning” epigastric pain,

episodic, +/- UGIB, gastric outlet obstruction

Worsened w/ eating (GU), begins hours after

meal/alleviated by eating (DU)

DX: H. pylori serology/breath/stool, EGD BX

TX: “Triple therapy” – PPI, Amox,

Clarithromycin (“Prevpac”). Quadruple w/

Pepto an option also.

Gastric Cancer

MC Adenocarcinoma - M>W, older (40+).

Lymphoma rare, but non-Hodgkins mets MC

to GI

S/SX: Dyspepsia, wt loss, anemia, GIB,

Virchow node (supraclavicular), Sister Mary

Joseph’s nodule (periumbilical)

DX/TX: EGD w/ BX, CT, resection w/ or w/o

rads/chemo

Gastric Cancer

Pyloric Stenosis

Narrowing of opening (pylorus) between

stomach and duodenum

M>F 4:1, infants 3 wks. - 5 mos.

S/SX: Forceful non-bilious vomiting soon

after feeding, fussy/hungry, palpable olive-

shaped mass (pylorus) in upper abdomen,

hypochloremic/hypokalemic met acidosis

DX/TX: Clinical HX/exam, abd U/S, surgery

Pyloric Stenosis

GALLBLADDER

Acute / chronic cholecystitis

Cholangitis

Cholelithiasis

Gallbladder Disease

S/SX: Episodes of colicky, RUQ pain often

after a fatty meal. Five F’s. +/- Fever, N/V.

+ Murphy’s sign - fingers under R costal

margin, pt. inspires deeply, winces & stops

due to pain/GB inflammation.

+ Boas’ sign - pain may occasionally radiate

to tip of R scapula

Gallbladder Disease

DX: WBC, LFTs,

U/S (gallstones w/

acoustic shadowing,

pericholecystic fluid,

GB wall thickening >

3 mm), HIDA scan

TX:

Cholecystectomy,

ERCP

Spectrum of Gallbladder Dz

Gallbladder Buzzwords

Five F’s - “Female, Forty, Fat, Fair & Fertile”

Charcot’s Triad - RUQ pain, jaundice & fever

Reynolds’ Pentad - Charcot’s + AMS/hypoTN

Above = likely septic w/ cholangitis, high mortality

Courvoisier’s Sign - pt. w. painless jaundice

and palpable, NT enlarged GB = cancer at

head of pancreas

LIVER

Acute / chronic hepatitis

Cirrhosis

Neoplasms

Hepatitis

Inflammation of liver (infectious vs.

non-infectous)

S/SX: Jaundice (>70%), vague abd

discomfort (most likely RUQ), nausea,

pruritis, tea-colored urine & clay-colored

stool, flulike prodrome

Hepatitis

DX/TX: LFTs, hepatitis

panel. Supportive care,

interferon/nucleoside

analogues. Vaccinate

against other forms.

Concurrent HIV TX

PRN. Liver txplt.

Viral Hepatitidies (sp???)

Hep A (acute, fecal/oral)

Hep B (acute & chronic, sex/blood)

Hep C (acute & chronic, IVDU MC, blood/sex)

Hep D (only as co-infection w/ Hep B)

Hep E (acute, fecal/oral, 20% mortality preg F)

Vaccines available for Hep B/C

Needlestick risks = Hep B 6-30% 😯

Hep C 1.8%, HIV 0.3%

Hepatitis

ETOH-related

AST:ALT > 2:1

Toxic (Tylenol OD)

Rumack-Matthew

nomogram for

acute OD, give N-

acetylcystine (NAC)

if indicated - not

useful for chronic

ingestion, however

Autoimmune

Alphabet soup!

Hep B rundown, as simple as I can make it?!

Acute Hep B = HBsAg+, IgM anti-HBc+

Prior HBV infxn, now immune = HBsAg-, anti-

HBs+, anti-HBc+

Received HBV vaccine = HBsAg-, anti-HBs+,

anti-HBc-

Hep B Chronic carrier = HBsAg+, IgM anti-

HBc-, anti-HBc(total)+

Hepatitis Serology

Cirrhosis

Injury to liver causing necrosis & fibrosis

(ETOH, hepatitis, drugs, biliary issues, etc.)

S/SX: Jaundice, portal HTN, ascites, hep

encephalopathy, asterixis/flap, easy bleeding

DX & TX: LFTs along w/ CBC, renal function,

PT/INR, CT/MRI

Liver Cancer

Hepatocellular carcinoma caused by

cirrhosis, Hep B/C/D, aflaxtoxin, etc.

S/SX: 1/3 aSX initially, abd pain, S/SX of

chronic liver dz

DX: LFTs, Elevated alpha-fetoprotein (70%),

paraneoplastic syndromes, imaging showing

mass, BX

TX: Resection/txplt, chemo/rads, poor

prognosis

PANCREAS

Acute / chronic pancreatitis

Neoplasms

Pancreatitis

Inflammation & autodigestion of the pancreas

Acute MC causes: ETOH, gallstones

Chronic MC cause: ETOH

S/SX: Mid-epigastric/upper abd pain w/

radiation to back, worse lying flat, N/V

Cullen’s sign: periumbical ecchymosis

Grey-Turner’s sign: flank ecchymosis

Pancreatitis

Pancreatitis

DX: Elevated lipase (>300, but may be

normal in chronic) & amylase (non-specific),

U/S to r/o gallstones if new DX, CT in some

cases to eval for pseudocyst/necrotic

elements

TX: Bowel rest / NPO, IVF, pain control

Ranson’s Criteria at time of admit (‘Don’t

mess with the “GA LAW!”’) and 48h later to

estimate mortality

Pancreatic Cancer

Adenocarcinoma of pancreatic duct

M>F 2:1, typically older (70-80) but

exceptions (ex: Steve Jobs)

S/SX: Abd pain, jaundice, wt. loss, N/V

DX: Labs, CT, endoscopic U/S w/ FNA BX

TX: Surgery/Whipple procedure in select few,

chemo/rads.

Overall prognosis = bad. 1 yr 20%, 5 yr 7%

SMALL INTESTINE / COLON

Appendicitis

Celiac disease

Lactose Intolerance

Constipation

Diverticular disease

Intussusception

Inflammatory Bowel Disease

Irritable Bowel Syndrome

SMALL INTESTINE / COLON

Ischemic Bowel Disease

Neoplasms

Obstruction

Polyps

Toxic Megacolon

Appendicitis

Inflammation of the appendix caused by

obstruction of appendiceal lumen by fecalith

MC surgical emergency - typically 10-30 y/o

S/SX: Periumbilical pain migrating to RLQ

(McBurney’s point), anorexia, N/V, +/- fever

Psoas, Rovsing & Obturator signs as well

DX: WBC, CT/US, lap appy alone to DX/TX if

your surgeon is convinced by HX/exam, ABX

PRN perf’ed/sick

Appendicitis PE Made Easy

A = McBurney’s Point

B = Rovsing’s

C = Psoas

D = Obturator

Celiac Disease

Gluten-sensitive enteropathy

characterized by malabsorption

S/SX: Diarrhea, steatorrhea,

bloating, wt. loss, rash

DX/TX: Antibody testing, small

bowel BX, response to gluten-

free diet - no wheat/barley/rye.

Rice/corn/oats OK.

Lactose Intolerance

Insufficient lactase enzyme leading to

fermentation of lactose by intestinal bacteria

w/ subsequent gas/acid production

MC among Asian Americans (>85%)

S/SX: Abd. bloating, gas, cramping, diarrhea

DX: Clinical, lactose breath H+ test to confirm

TX: Lactose-free diet, lactase enzyme

supplements (Lactaid, Dairy-Ease)

Constipation

If you need a formal definition: < 3 BMs a

week, hard/painful to pass. < 1 = severe

S/SX: Surely you don’t need my help w/ this?

DX: MRI, colonic content BX (just kidding…)

TX: Fiber > 20-35g/day, fluids, exercise, stool

softeners, laxatives (osmotic, stimulant, etc.)

Biggest thing? Watch for red flags. Wt loss,

severe abd pain, obstructive SX, blood.

Diverticular Disease

Diverticulosis = saclike protrusions of colonic

mucosa herniated thru defect in muscle layer

S/SX: Most aSX, painless rectal bleeding in some

Diverticulitis = inflammation/perf of diverticuli

S/SX: LLQ pain, +/- fever, +/- bleeding

DX: WBC, CT, empiric TX if HX of same/mild

TX: ABX (Cipro/Flagyl vs. Zosyn), bowel rest, pain

control, surgery in complicated/recurrent cases

Intussusception

Occurs when portion of intestine telescopes

inside another portion - causes pain, possible

obstruction/bowel ischemia. MC 3 mos.-3 yrs.

S/SX: Colicky/episodic pain increasing in

duration/freq, pulling knees to chest, N/V,

“currant jelly stools,” sausage-shaped lump

DX/TX: IVF, U/S showing “bulls-eye,”

air/barium enema (often DX/curative),

surgery PRN otherwise

Intussusception

Inflammatory Bowel Disease

Crohn’s = Transmural inflammation (all

layers) of bowel, spares rectum in some

S/SX: Abd pain, +/- bloody diarrhea w/

skip lesions, cobblestoning, abscess/fistula,

perianal dz., aphthous ulcers

Ulcerative Colitis = inflammation of mucosa

alone, always starts in rectum

S/SX: Abd pain, bloody diarrhea w/ continuous

lesions, “lead pipe” colon, 30x ↑ colon ca risk

Crohn’s Disease

DX: CT, endoscopy/colonoscopy w/ BX

TX: Sulfasalazine or mesalamine, PO steroid

taper, immunosuppressants, surgery

Ulcerative Colitis

DX: Sigmoidoscopy w/ BX

TX: Sulfasalazine or mesalamine, PO steroid

taper, immunosuppressants, surgery

Irritable Bowel Syndrome

Functional disorder w/o clear/known etiology

or underlying damage. Often comorbid w/

psych issues, chronic fatigue.

S/SX: Abd. pain, bloating & alteration in

bowel patterns (diarrhea, constipation, both)

DX: R/O alt causes (infection, celiac dz., IBD,

malignancy), Manning/Rome criteria

TX: Diet, fiber, mood, laxatives,

antidiarrheals, antispasmodics

Ischemic Bowel Disease

Inflammation, injury & potential death of

portion of lg. intestine 2/2 inadeq. blood

supply - vascular dz., clot, low-flow state

MC affects superior mesenteric a., older pt.

w/ HX of CAD/A. fib and/or septic/hypoTN

S/SX: Acute = “pain out of proportion to

exam”, melanotic/bloody stool

Chronic = pain shortly after eating, wt. loss

Ischemic Bowel Disease

DX: Mesenteric angiogram, CT

TX: IVF, bowel rest, +/- ABX, surgery PRN

Colorectal Cancer

Neoplasm arising from lumen of lg. bowel -

2nd MC cancer death in US, peak 70 y/o

Risk factors: FHX, IBD, age, diet, hereditary

polyposis.

S/SX: Initially vague w/ malaise, anorexia, wt

loss. Progressing to pain, rectal bleeding

obstruction.

DX: Colonscopy w/ BX, “apple core” lesion on

barium enema, anemia, CEA (tumor marker)

Colorectal Cancer

Bowel Obstruction

Partial or complete blockage of small or large

bowel due to adhesions, hernia, fecal

impaction, volvulus or neoplasm/mass

S/SX: Abd. pain, distention, absence of

flatus/stool. Hyperactive BS progressing to

hypoactive/absent.

D/DX: “Air-fluid levels,” “string of pearls” on

XR for SBO, “coffee bean”/”bent innertube”

for volvulus - CT definitive

TX: Bowel rest, NG tube, surgery PRN

SBO XR

Volvulus XR

RECTUM

Anal fissure

Abscess / fistula

Fecal impaction

Hemorrhoids

Neoplasms

Anal Fissure

Tear in epithelial lining of anal canal

S/SX: Tearing pain w/ defecation, BRB on TP

DX: Clinical - typically posterior (90%) or

anterior midline. If not or deeper, purulent,

abnl. appearance - consider alt. etiology?

TX: Sitz baths, stool softener, NTG ointment

Abscesses & Fistulas

Purulent fluid collection and/or abnormal

communication between anal canal and

perianal skin. Can be linked to IBD.

S/SX: Fluctuant/draining swelling or

open/communicating fistula around anus.

Tenderness/mass on DRE.

DX: Clinical exam. CT w/ contrast to

determine extent/depth or communication.

TX: I&D abscess in appropriate setting,

surgery, manage underlying condition (IBD)

Fecal Impaction

The name says it all – need I say more?

Consider red flags such as neoplasm if not

c/w stool bolus alone.

S/SX: Constipation or scant watery diarrhea

around impacted stool.

DX: DRE, imaging PRN

TX: DRE, enemas, DisImpactor to the

rescue!

Hemorrhoids

Varices of hemorrhoidal plexus either above

(internal) or below (external) dentate line

S/SX: BRB on TP, pain & pruritus (external),

thrombosis (external)

DX: Clinical, anoscopy

TX: Sitz baths, fluids & fiber, stool softener,

topical hydrocortisone/witch hazel,

suppositories. I&D clot. Surg/banding PRN.

MISCELLANEOUS

Hernias

Infectious & Noninfectious Diarrhea

Vitamin & Nutritional Deficiences

Phenylketonuria

Hernias

Exit of an organ through wall of cavity in

which it normally resides

Various types - hiatal, umbilical, ventral,

femoral, inguinal, incisional

Associations: Hiatal (GERD or newborns),

umbilical (congenital/infants), femoral

(elderly F’s), inguinal (lifting/strain)

Hernias

Indirect inguinal hernia (MC) - through

internal inguinal ring into inguinal canal

Direct inguinal hernia - through external

inguinal ring / Hesselbach’s triangle

DX: Clinical - CT PRN to eval for obstruction,

incarceration, strangulation

TX: Manual reduction, surgery PRN

Hernias

Infectious Diarrhea

Bacillus cereus = reheated/fried rice

Campylobacter = undercooked/raw poultry

C. botulinum = home canning, honey < 1 y/o

C. difficile = ABX (3 C’s: Clinda, Cipro, Ceph)

E. coli = fecal-oral, ”traveler’s diarrhea”

Giardia = camping, streams/creeks

Infectious Diarrhea

Listeria = unpasterurized milk/chz, deli meats

Salmonella = Eggs, poultry, meat

Shigella = Bloody/mucoid diarrhea, dysentery

Staph aureus = Potato salad, mayo, QUICK!!!

Vibrio = shellfish, “rice water stools,” cholera

Vitamin A

At risk: Elderly, ETOH’ics

Night blindness, dry skin, poor wound healing

Thiamine (B1)

At risk: ETOH’ics, poor

Wernicke’s encephalopathy, Korsakoff syndrome,

Beriberi (wet & dry)

Vitamin & Nutritional

Deficiencies

Vitamin & Nutritional

Deficiencies

Niacin (B3)

At risk: ETOH’ics, poor

Pellagra/3 D’s (diarrhea, dermatitis & dementia)

Cobalmin (B12)

At risk: Elderly, vegans, atrophic

Vitamin C

At risk: ETOH’ics, elderly

Scurvy (bleeding gums, petechiae, poor healing)

Vitamin & Nutritional

Deficiencies

Vitamin D

At risk: Elderly, low sunlight, infants

Rickets, osteomalacia

Vitamin K

Bleeding, elevated PT

Phenylketonuria

Hereditary/recessive familial disease w/

deficiency of phenylalanine hydroxylase,

which is an enzyme responsible for

processing amino acid/building blocks of

protein in diet

Screened for at birth - can cause MR, musty

odor to urine, vomiting, convulsions, irritability

TX: Low phenylalanine diet, tyrosine supp.

REMEMBER – IT’S NOT

EXACTLY BRAIN SURGERY…

Practice Questions…

A 72 y/o F presents w/ difficulty

swallowing solids - daughter reports

halitosis along w/ “coughing up bits of

food sometimes.” She also has HX of

recent admit for asp. PNA. What underlying

condition is likely causing her dysphagia?

Achalasia

CVA w/ resultant neuromuscular dysfunction

ETOH’ism

Zenker’s diverticulum

Schatzki’s ring

Which of the following meds is typically

not included as a part of either triple or

quadruple therapy for PUD?

Amoxicillin

Lansoprazole

Carafate

Bismuth subsalicylate

Clarithromycin

A 24 y/o F presents w/ c/o R flank pain,

anorexia, N/V and fever. UPT neg, U/A

w/ leuks, many epis but no nitrites/blood and

neg gram stain. WBC 19. She endorses pain

when you hyperextend R leg at hip. What is

most likely cause?

Pyelonephritis

Acute cholecystitis

Infected kidney stone

Retrocecal appendicitis

Gastroenteritis

While staffing a local UC, you have

3 patients who come in simultaneously

w/ N/V/D after attending a church potluck

earlier that afternoon. All are afeb, nontoxic

w/ benign abds and NBNB N/V/D. What is the

most likely organism causing their SX?

C. difficile

Campylobacter

Salmonella

Giardia

Staph aureus

What acute abdominal pathology can

present with abd distention, hypoactive

bowel sounds, NBNB N/V and “air-fluid

levels” on screening acute abd XR?

Volvulus

Perforated ulcer

Strangulated hernia

Small bowel obstruction

Thrombosed hemorrhoid

Questions, Feedback?

EM: brock.phillips.pac@gmail.com

Twitter: @BPhilPAC

THANK YOU!!! Evals appreciated!