PANCE Blueprint GI and Nutrition (10%)

PANCE Blueprint GI and Nutrition (10%)

PANCE Blueprint GI and Nutrition (10%)

Follow along with the NCCPA™ PANCE and PANRE Gastroenterology and Nutrition Content Blueprint

  • 50 PANCE and PANRE Gastroenterology Content Blueprint Lessons (FREE)
  • 149 Question Gastroenterology Exam (members only)
  • Gastroenterology Pearls Flashcards (members only)
  • Picmonic™ Integrated Blueprint lessons
  • 7 Gastroenterology Content Blueprint high-yield summary tables (FREE)
  • ReelDx integrated video content (available to SMARTYPANCE ReelDx level subscribers)

Lessons

  1. Gastroenterology System Flashcards

    1. GI/Nutrition Quick Cram Cards

  2. GI and Nutrition 149 Question Comprehensive Exam (Members Only)

  3. GI and Nutrition Content Blueprint Cram Session

    1. Acute and chronic cholecystitis (Lecture)

      The 5 F's: Female, Fat, Forty, Fertile, and Fair
      • (+) Murphy's sign (RUQ pain with GB palpation on inspiration)
      • RUQ pain after high fat meal
      • Ultrasound is the preferred initial imaging
      • HIDA scan is the best test (Gold Standard)
      • Porcelain gallbladder = chronic cholecystitis
      • Treat with laparoscopic cholecystectomy
    2. Cholangitis

      Cholangitis is a complication of gallstones with symptoms secondary to an infected obstruction of the common bile duct (E.coli is the #1 cause)
      • Charcot’s triad: RUQ tenderness, jaundice, fever
      • Reynold’s pentad: Charcot’s triad + altered mental status and hypotension
      • ERCP is the optimal procedure both for diagnosis and for treatment
  4. Colorectal disorders (PEARLS)

    1. Anorectal abscess is a result of infection, whereas fistula is a chronic complication of an abscess.
      • Produce painful swelling at the anus as well as painful defecation. Examination reveals localized tenderness, erythema, swelling, and fluctuance; fever is uncommon.
      • Deeper abscesses may produce buttock or coccyx pain and rectal fullness; fever is more likely.
      Anorectal fistula is an open tract between two epithelium-lined areas and is associated with deeper anorectal abscesses
      •  Fistulae will produce anal discharge and pain when the tract becomes occluded.
    2. Tearing rectal pain and bleeding which occurs with or shortly after defecation, bright red blood on toilet paper. Pain lasts for several hours and subsides until the next bowel movement
    3. Constipation is defined as any two of the following features: straining, lumpy hard stools, a sensation of incomplete evacuation, use of digital maneuvers, a sensation of anorectal obstruction or blockage with 25 percent of bowel movements, and decrease in stool frequency (less than three bowel movements per week).
      • Increase fiber (20-25 grams per day), exercise and water in diet
      • Bulk-forming laxatives first line and osmotic laxatives can be used in patients not responding satisfactorily to bulking agents
      • Patients who are older than 50 with new onset constipation should be evaluated for colon cancer
    4. Defined as an out-pocketing of colon wall - most common location is the sigmoid colon
      • Diverticulosis: Painless rectal bleeding
      • Diverticulitis: Presents with constipation. LLQ pain, Fever, ↑ WBC, and generally don't bleed
      • Diagnose with CT: Fat stranding and bowel wall thickening
      • Treatment: Metronidazole and Ciprofloxacin + bowel rest
    5. Belly cramping and bloating, small amount of stool leakage and rectal discomfort in an elderly bed-bound patient
    6. External- lower 1/3 of anus (below dentate line)
      • Significant pain, and pruritus but no bleeding, treat with excision for thrombosed external hemorrhoids
      Internal- upper 1/3 of anus
      • No Pain, bright red blood per rectum, pruritus and rectal discomfort, treat with fiber, sitz baths, reduction if needed
    7. Ulcerative Colitis
      • Isolated to the colon starts at rectum and moves proximally
      • Continuous lesions
      • Mucosal surface only
      • Barium enema: Lead pipe appearance (loss of haustral markings)
      • Medications: Prednisone and mesalamine
      • Colectomy is curative
      Crohn's disease 
      • From mouth to anus, transmural, skip lesions, and cobblestoning
      • Transmural
      • Fistulas common
      • Flares: Prednisone +/- Mesalamine +/- Metronidazole or Ciprofloxacin. Maintenance: Mesalamine
      • Surgery is not curative
    8. According to the Rome IV criteria, IBS is defined as recurrent abdominal pain, on average, at least one day per week in the last three months, associated with two or more of the following criteria:
      • Related to defecation
      • Associated with a change in stool frequency
      • Associated with a change in stool form (appearance)
    9. Sudden onset abdominal pain occurring 10-30 minutes after eating in a patient (usually elderly) with a risk of emboli formation (on the exam it is usually atrial fibrillation or CHF). It is associated with bleeding per rectum with or without diarrhea. Physical examination findings are usually disproportionate with abdominal pain.
      • Most common artery: Superior mesenteric artery
      • Acute: Abdominal pain out of proportion to findings
      • Chronic: pain 10-30 mins after eating, relieved by lying or squatting
      • Mesenteric angiography is the gold standard for diagnosis
      • Revascularization is the gold standard treatment
    10. Colonic polyps are common; the incidence ranges from 7% to 50% (depending on the diagnostic method used)
      • The main concern is malignant transformation, which occurs at different rates depending on the size and type of polyp
        • Distal colon are commonly benign if seen in the proximal colon they are more likely to be cancerous
        • The larger the colonic polyp, the greater the risk of malignant transformation
        • Villous adenomas have a 30-70% risk of malignant transformation
        • The greater the number of concomitant colonic polyps, the greater the risk of malignant transformation
      • Most common cause of painless rectal bleeding in the pediatric population
      • Once identified follow-up colonoscopy in 3-5 years
      Familial adenomatous polyposis (FAP) - is characterized by the development of hundreds to thousands of colonic adenomatous polyps
      • Colorectal polyps develop by mean age of 15 years and cancer at 40 years
      • First-degree relatives of patients with FAP should undergo genetic screening after age 10 years
      • The family should undergo yearly sigmoidoscopy beginning at 12 years of age
    11. Complication of Ulcerative colitis (most common)Crohn’s, Hirschsprung’s, pseudomembranous colitis, enteritis. KUB shows dilated colon > 6 cm and colonic distention, fever, markedly distended abdomen, peritonitis, and shock.
    1. Esophagitis (ReelDx)

      Non-infectious esophagitis
      • Reflux esophagitis: mechanical or functional abnormality of the LES
      • Medication induced: think NSAIDS or bisphosphonates
      • Eosinophilic: Pt with Asthma symptoms and GERD not responsive to antacids. Allergic, eosinophilic infiltration of the esophageal, barium swallow will show multiple corrugated rings
      Infectious esophagitis
      • Fungal: Infectious Candida: linear yellow-white plaques with odynophagia or pain on swallowing. Tx with Fluconazole 100 mg PO daily
      • Viral:
        • HSV: shallow ulcers noted on EGD, treat with acyclovir
        • CMV: deep ulcers on EGD, treat with ganciclovir
      • EBV, Mycobacterium tuberculosis, and Mycobacterium avium intracellulare are additional infectious causes
    2. Motility disorders

      • Achalasia: failure of LES relaxation and increased LES tone, decreased peristalsis, slowly progressive dysphagia, episodic regurgitation, barium swallow: “parrot-beak” - dilated esophagus tapered to distal obstruction. Dysphagia to liquids and solids. Definitive diagnosis: esophageal manometry
      • Diffuse Esophageal SpasmCorkscrew appearance on barium swallow
      • Neurogenic dysphagia: Dysphagia to liquids and solids caused by injury at brainstem or cranial nerves
      • Zenker diverticulum:  Outpouching of posterior hypopharynx - regurgitation of undigested food and liquid into the pharynx several hours after eating, foul odor of breath. Diagnose with barium swallow. 
      • Scleroderma esophagus: decreased esophageal sphincter tone and peristalsis, dysphagia to both solids and liquids
      • Esophageal stenosis: Dysphagia to solids but not liquids
    3. Retrosternal pain/burning shortly after eating worse with carbonation, greasy foods, spicy foods and laying down
      • Endoscopy with biopsy—the test of choice but not necessary for typical uncomplicated cases. Indicated if refractory to treatment or is accompanied by dysphagia, odynophagia, or GI bleeding.
      • Upper GI series (barium contrast study)—this is only helpful in identifying complications of GERD (strictures/ulcerations)
      • PH Probe is gold standard for diagnosis (but usually unnecessary)
      • H2 receptor blockers, proton pump inhibitors, diet modification (avoid fatty foods, coffee, alcohol, orange juice, chocolate; avoid large meals before bedtime); sleep with trunk of body elevated; stop smoking
      • Nissen fundoplication: antireflux surgery for severe or resistant cases
      • Complications: Strictures or Barrett’s esophagus
    4. Esophageal mucosal tear caused by forceful vomiting - history of alcohol intake and an episode of vomiting with blood
    5. Solid food dysphagia in a patient with a history of GERD
      • Esophageal web: thin membranes in the mid-upper esophagus. May be congenital or acquired. Plummer-Vinson - esophageal webs + dysphagia + iron deficiency anemia
      • A Schatzki ring is a diaphragm-like mucosal ring that forms at the esophagogastric junction (the B ring). If the lumen of this ring becomes too small, symptoms occur
      • Diagnosed with barium swallow and treated with endoscopic dilation
    6. Esophageal varices (ReelDx)

      Dilated veins in the distal esophagus or proximal stomach caused by elevated pressure in the portal venous system, typically from cirrhosis. Budd-Chiari syndrome (from occlusion of hepatic veins), treat with therapeutic endoscopy – endoscopic banding and IV octreotide, prevent with nonselective beta blockers
  5. Food allergies and food sensitivities (PEARLS)

    1. Celiac disease

      Small bowel inflammation from allergy to gluten
      • Symptoms usually occur following ingestion of gluten-containing food (diarrhea, steatorrhea, flatulence, and weight loss). Also, has extraintestinal manifestations.
      • IgA anti-endomysial and anti-tissue transglutaminase antibodies
      • Small bowel biopsy is gold standard for diagnosis
      • Treatment: Lifelong gluten free diet
    2. Symptoms may include abdominal bloating and cramps, flatulence, diarrhea, nausea, borborygmi (rumbling stomach), or vomiting after consuming significant amounts of lactose
      • Lactose hydrogen breath test - definitive diagnosis
      • Treatment focuses on avoidance of dairy products, use of lactose-free products, or the use of lactase supplements
    3. Nut allergies

      Nuts are one of the food allergens most often linked to anaphylaxis
      • Nut allergies usually last a lifetime; fewer than 10 percent of people with this allergy outgrow it.
      Treatment: Avoid nuts and nut products; read ingredient labels carefully. Administer epinephrine as soon as severe symptoms develop.
    1. Gastritis

      Dyspepsia and abdominal pain - Gold standard diagnosis is endoscopy with 4 biopsies along stomach lining
      • Autoimmune or hypersensitivity reaction (e.g. pernicious anemia)
        • Pernicious anemia: + schilling test + ↓ intrinsic factor and parietal cell antibodies
      • Infection - H. pylori (most common)
        • Studies: Urea breath test or fecal antigen
        • Treatment: PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole
      • Inflammation along the stomach lining (NSAIDS and Alcohol)
        • NSAIDS: cause gastric injury by diminishing local prostaglandin production in the stomach and duodenum
        • Alcohol: a leading cause of gastritis
      • H. pylori (most common), NSAID use, Zollinger-Ellison syndrome (refractory PUD) - gastrin secreting tumor
        • Duodenal ulcer - pain improves with food
        • Gastric ulcer - pain worsens with food
      • Diagnosis: Endoscopy with biopsy is gold standard for diagnosis
      • Treatment:
        • H. pylori infection: Triple therapy PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole
        • NSAIDs use: discontinue use
        • Zollinger-Ellison syndrome: PPI and resect tumor
    2. Pyloric stenosis (ReelDx)

      Projectile vomiting occurring shortly after feeding in an infant < 3 mo old with a palpable "olive-like" mass  at the lateral edge of the right upper quadrant
      • On ultrasound you will see a “double-track”
      • Barium studies will reveal a “string sign” or “shoulder sign”
      • Hepatitis A
        • Acute - fatigue malaise, nausea, vomiting, anorexia, fever and right upper quadrant pain.
        • Transmission: Fecal-oral
        • Serum IgM anti-HAV
        • Vaccine: killed (inactivated) - given in two doses, recommended for travelers.
      • Hepatitis B
        • Acute and Chronic
        • Transmission: Sexual or sanguineous
        • Serology:
        • HBeAg – highly infectious
        • HBsAg – ongoing infection
        • Anti-HBc – had/have infection
          • IgM – acute
          • IgG – not acute
        • Anti-HBs – immune
        • Risk of hepatocellular carcinoma
        • Vaccine is given to all infants (birth, 1-2 mo, 6-18 mo)
      • Hepatitis C
        • Chronic
        • Asymptomatic
        • Transmission: IV drug use is most common. Also sexual or sanguineous
        • Screen with testing for anti-HCV antibodies
        • Diagnosis with HCV RNA quantitation
        • Risk of cirrhosis and hepatocellular carcinoma
        • Treatment: antiretrovirals target complex of enzymes needed for HCV RNA synthesis
      • Hepatitis D
        • Only occurs when coinfected with Hepatitis B
        • Risk of hepatocellular carcinoma
      • Hepatitis E
        • Pregnant woman, 3rd world countries
        • Hepatitis E + mother = high infant mortality
    1. Cirrhosis is a late stage of hepatic fibrosis that has resulted in widespread distortion of normal hepatic architecture
      • Chronic hepatitis is the most common cause of cirrhosis (21%) Alcohol abuse is second (21%)
      • Labs:  AST > ALT, ↑ risk for hepatocellular carcinoma: monitor AFP, ↑ ALP and GGT, low albumin, prolonged PT
      • Hepatic vein thrombosis = Budd Chiari: triad of abdominal pain, ascites and hepatomegaly
      • Ascites, pulmonary edema/effusion, esophageal varices, Terry’s nails (white nail beds)
      • Skin changes: spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput medusae, hyperpigmentation
      • Hepatic encephalopathy: Asterixis (flapping tremor), dysarthria, delirium,  and coma
  6.  
    • Inguinal hernias:
      • Indirect Inguinal Hernia (Most Common): Passage of intestine through the internal inguinal ring down the inguinal canal, may pass into the scrotum. Often congenital and will present before age one.
      • Direct Inguinal HerniaPassage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum.
    • Hiatal (diaphragmatic): Involves protrusion of the stomach through the diaphragm via the esophageal hiatus.  It can cause symptoms of GERD; acid reduction may suffice, although surgical repair can be used for more serious cases.
    • Ventral: Often from previous abdominal surgery, obesity.  Abdominal mass noted at site of previous incision.
    • Umbilical hernia: Very common, generally is congenital and appears at birth.  Many umbilical hernias resolve on their own and rarely require intervention. Refer to surgery if an umbilical hernia persists >2 years of life.
    • Strangulated: Hernia becomes strangulated when the blood supply of its contents is seriously impaired.
    • Obstructed: This is an irreducible hernia containing intestine that is obstructed from without or within, but there is no interference to the blood supply to the bowel. 
    • Incarcerated: Hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.
    • Traveler's diarrhea: e-coli.
    • Diarrhea after a picnic and egg salad: Staphylococcus Aureus.
    • Diarrhea from shellfish: Vibrio cholerae.
    • Diarrhea from poultry or pork: Salmonella.
    • Diarrhea in a patient post antibiotics: C. Difficile.
    • Diarrhea in poorly canned home foods: C. perfringens.
    • Diarrhea breakout in daycare center: Rotavirus.
    • Diarrhea on a Cruise Ship: Norovirus.
    • Diarrhea after drinking (not so) fresh mountain stream water: Giardia lamblia - incubates for 1-3 weeks, causes foul smelling bulky stool and may wax and wane over weeks before resolving.
  7. Metabolic Disorders (PEARLS)

    1. G6PD deficiency

    2. Phenylketonuria (PKU) is an autosomal recessive disorder and inborn error of metabolism involving absent or virtually absent phenylalanine hydroxylase (PAH) enzyme activity.
      • Phenylalanine and its metabolites accumulate in the central nervous system, causing mental retardation and movement disorders.
      • Infants are normal at birth - after a few months, mental retardation is evident.
      • Presents as blond, blue-eyed, with fair skin, mental retardation, eczema, and a musty, mousy body odor of phenylacetic acid.
      • Neonates are screened for PKU 24 to 48 h after birth.
      • Treatment: Low phenylalanine diet and tyrosine supplementation by age 3.
    1. Esophageal Neoplasms (Lecture)

      Progressive dysphagia to solid foods along with weight loss, reflux and hematemesis
      • Squamous cell m/c worldwide and adenocarcinoma common in US
      Adenocarcinoma:
      • Complication of Barrett's esophagus (screen barrett's patients every 3-5 years with endoscopy), affects distal (lower) 1/3rd of esophagus
      Squamous cell:
      • Associated with smoking and alcohol use
      • Affects proximal (upper) 2/3rds of esophagus
    2. Gastric neoplasms (Lecture)

      Weight loss, early satiety, abdominal pain/fullness and dyspepsia
      • Adenocarcinoma is most common
      • Metastatic signs include
    3. Liver neoplasms (ReelDx)

      Presentation: Abdominal pain, weight loss and right upper quadrant mass
      • Etiology: Cirrhosis, Hepatitis B, Hepatitis C, Hepatitis D, Aflatoxin from aspergillus
      • Tumor Marker: ↑ alpha-fetoprotein and abnormal liver imaging
    4. Painless jaundice is pathognomonic
      • Most commonly ductal adenocarcinoma located at pancreatic head
      • Presentation:
        • Jaundice and palpable non-tender gallbladder (Courvoisier’s sign)
        • Trousseau sign of malignancy - migratory phlebitis
        • Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle) that is associated with pancreatic cancer
      • Diagnose with abdominal CT scan - 75% show tumor at the head of the pancreas, 25% at the tail
      • Whipple procedure: remove antrum of stomach, part of duodenum, head of pancreas, gall bladder
      • Tumor Marker: CA 19-9
    5. Rectal bleeding + tenesmus (a feeling of incomplete emptying after a bowel movement), the most common anorectal cancer is adenocarcinoma
      • Primarily adenocarcinomas.
      • Typically colonoscopy is done: whenever rectal bleeding occurs, even in patients with obvious hemorrhoids or known diverticular disease, coexisting cancer must be ruled out.
      • Treated with wide local surgical excision, radiation with chemotherapy for large tumors with mets.
    6. Painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age
      • Apple core lesion on barium enema, adenoma most common type,
      • Screening with colonoscopy begins at 50 then every 10 years until 85
        • Fecal occult blood testing - annually after age 50
        • Flexible sigmoidoscopy - every 5 years with FOB testing
        • Colonoscopy - every 10 years
        • Sometimes CT colonography
      • Tumor Marker: CEA
      • More likely to be malignant: sessile, > 1 cm, villous
      • Less likely to be malignant: Pedunculated, < 1 cm, tubular
      • Treat with resection and adjuvant chemotherapy
  8. Nutritional and vitamin disorders (PEARLS)

      • Kwashiorkor is inadequate intake of protein and may lead to edema.
      • Marasmus is inadequate intake of ALL energy forms (including protein).
      • Fat Soluble Vitamins (ADEK):
        • Vitamin A: Elderly, alcoholics, liver disease - night blindness, dry skin.
        • Vitamin D: Elderly, low sunlight - rickets, osteomalacia.
        • Vitamin E: neuropathy, ataxia
        • Vitamin K: bleeding (makes clotting factors causes an increase in PT/INR).
      • Vitamin C: Alcoholics, elderly men - scurvy (poor wound healing, petechiae, bleeding gums).
      • Thiamine (B1): Alcoholics, poverty - Beriberi (tingling, poor coordination, edema, cardiac dysfunction).Wernicke’s encephalopathy (ataxia, confusion). Korsakoff syndrome (confabulation, retrograde and anterograde amnesia).
      • Niacin (B3): Poverty, alcoholics - Pellagra (diarrhea, dermatitis, dementia).
      • Pantothenic Acid (B5): Alcoholics - Numbness, tingling, headache, fatigue, insomnia.
      • Pyridoxine (B6): Adolescents, alcoholics - Dermatitis, atrophic glossitis, sideroblastic anemia.
      • Folate: Pregnancy, alcoholics - Neural tube defects, megaloblastic anemia, glossitis, confusion.
      • Cobalamin (B12): Elderly, vegans, atrophic gastritis - Megaloblastic anemia, subacute combined degeneration of spinal cord, seizures, dementia.
    1. Obesity

      Definition of obesity: 
      • Adults BMI = 30 kg/ m2 or, alternatively, 20% higher than suggested ideal body weight
        • Normal: BMI of 18.5 to 24.9
        • Overweight: 25 to 29.9
        • Obese: 30 and over
        • Obesity class I: 30 to 34.9
        • Obesity class II: 35 to 39.9
        • Obesity class III: 40 and over
      • Children and adolescents BMI at the 95th percentile or higher
      Drug therapy— Candidates for drug therapy include those individuals with a (BMI) ≥ 30 or a BMI of 27 to 29.9 with comorbidities, who have not met weight loss goals (loss of at least 5 percent of total body weight at three to six months)
      • Orlistat
      • Liraglutide
      • Lorcaserin
      • Combination phentermine-topiramate 
      • Combination bupropion-naltrexone 
      • Phentermine, benzphetamine, phendimetrazine, and diethylpropion are only FDA approved for short-term use
      Guidelines to qualify for gastric bypass surgery
      • Efforts to lose weight with diet and exercise have been unsuccessful
      • (BMI) is 40 or higher
      • BMI is 35 or more and serious weight-related health problem, such as type 2 diabetes, high blood pressure or severe sleep apnea
    1. Acute Pancreatitis - epigastric abdominal pain with radiation to the back, elevated lipase, pain relieved by leaning forward, elevated lipase
      • Etiology: Cholelithiasis or alcohol abuse
      • Diagnosis:
        • Clinical + elevated lipase and amylase
        • CT required to differentiate from necrotic pancreatitis
      • Signs: Grey Turner's sign (flank bruising), Cullen’s sign (bruising near umbilicus)
      • Treatment: IV fluids (best), analgesics, bowel rest
      • Complication: pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)
      Ranson’s criteria for poor prognosisThe Ranson criteria form a clinical prediction rule for predicting the severity of acute pancreatitis.  Three or more means more severe course:
      • Age > 55
      • Leukocyte: >16,000
      • Glucose: >200
      • LDH: >350
      • AST: >250
      • Calcium: <8.0
      Chronic Pancreatitis - classic triad of pancreatic calcification (plain abdominal x-ray), steatorrhea (high fecal fat), and diabetes mellitus
      • Alcohol abuse
      • Treatment: no alcohol, low-fat diet
    1. Appendicitis (ReelDx)

      Umbilical pain → then pain over McBurney’s point (RLQ)
      • Nausea and vomiting, fever, chills, anorexia
      • Most common etiology: Acute inflammation of the appendix secondary to fecalith
      Signs: Treatment: Appendectomy
    2. Sudden onset of significant, colicky abdominal pain that recurs every 15 to 20 min, often with vomiting. Affects children after viral infections or adults with cancer
    3. Look for vomiting of partially digested food, severe abdominal distensions and high pitched hyperactive bowel sounds progressing to silent bowel sounds.
      • KUB shows dilated loops of bowel with air fluid levels with little or no gas in the colon
      • Etiology: Adhesion, hernia, fecal impact, volvulus, neoplasm
      • Treatment: Bowel rest, NG tube placement, surgery as directed by underlying cause

Teachers

The Daily PANCE and PANRE

Get 60 days of PANCE and PANRE Multiple Choice Board Review Questions delivered daily to your inbox. It's 100% FREE and 100% Awesome!

You have Successfully Subscribed!