PANCE Blueprint GI and Nutrition (9%)

Diseases of the Small Intestine (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE Content Blueprint covers five topics under the category diseases of the small intestine


Appendicitis (ReelDx)
ReelDx Virtual Rounds (Appendicitis )
Patient will present as → a 14-year-old boy with nausea, vomiting, constipation, and periumbilical pain that has settled in the lower right quadrant. The patient’s mom gave him a piece of toast and some water about 5 hours ago but he vomited 30 minutes after eating. On physical exam, he has tenderness and guarding in the lower right quadrant, pain upon flexion and internal rotation of right lower extremityRLQ pain with right hip extension, and RLQ pain with palpation of the LLQ. Blood tests reveal leukocytosis with a shift to the left.

The first symptom is crampy or "colicky" pain around the navel (periumbilical) → then pain over McBurney’s point (RLQ)

  • There is usually a marked reduction in or total absence of appetite, often associated with nausea, and occasionally, vomiting and low-grade fever
  • Most common etiology ⇒ fecalith
  • As the inflammation increases, the abdominal pain tends to move downward - begins in epigastrium → umbilicus → RLQ
  • Right lower quadrant= "McBurney's point." This "rebound tenderness" suggests inflammation has spread to
    the peritoneum


  • Rovsing – RLQ pain with palpation of LLQ
  • Obturator sign – RLQ pain with internal rotation of the hip
  • Psoas sign - RLQ pain with hip extension while laying on left side
    • Alternatively, the patient lies on their back, and the examiner asks the patient to actively flex the right hip against the examiner's hand

DX: Clinical diagnosis:

  • Imaging if atypical presentation - appy ultrasound or abdominal CT scan
  • CBC - neutrophilia supports the diagnosis

TX: surgical appendectomy

Celiac disease
Patient will present as → a 45-year-old male from Ireland with complaints of diarrhea, steatorrhea, flatulence, weight loss, weakness, and abdominal distension. He reports having 3-5 loose stools per day for the last six months. The condition improves when he fasts.

Small bowel inflammation from an allergy to gluten

  • Symptoms usually occur following the ingestion of gluten-containing food. Also, has extraintestinal manifestations.
    • Diarrhea, steatorrhea, flatulence, weight loss, weakness, and abdominal distention
  • Associated with dermatitis herpetiformis (chronic, itchy skin rash on elbow, knees, butt, scalp)
  • Associated conditions: T1DM, autoimmune hepatitis, autoimmune thyroid DZ, down, turner, Williams syndrome, increased incidence of small bowel lymphoma


  • IgA anti-endomysial (EMA) and anti-tissue transglutaminase (anti-TTG) antibodies
  • Small bowel biopsy (duodenum) is the gold standard

TX: Lifelong gluten-free diet

Intussusception (ReelDx)
ReelDx Virtual Rounds (Intussusception)

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

  • Currant jelly stools
  • Sausage-like mass in the abdomen
  • An abdominal x-ray will reveal a Crescent sign or a Bull's eye/target sign/coiled spring lesion” representing layers of the intestine within the abdomen
  • A barium enema is both diagnostic and therapeutic in children
Small bowel obstruction
ReelDx Virtual Rounds (Small bowel obstruction)
Patient will present as → a 65-year-old female with diffuse abdominal pain and vomiting. She has not had a bowel movement in three days. PE reveals high-pitched, hyperactive bowel sounds, tympany to percussion, no rebound tenderness, and a temperature of 100.4 F. Abdominal radiograph reveals distended loops of bowel with a step ladder pattern of differential air-fluid levels.
What are the 4 cardinal signs of strangulated bowel?
The 4 cardinal signs of strangulated bowel: fever, tachycardia, leukocytosis, and localized abdominal tenderness.

Small bowel obstruction

  • Colicky abdominal pain, nausea, bilious vomiting, obstipation, abdominal distention
  • Hyperactive bowel sounds (early) or hypoactive bowel sounds (late), prior abdominal surgery
  • Dehydration + electrolyte imbalances
  • MCC: adhesions or hernias, cancer, IBD, volvulus, and intussusception
  • KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon

Large bowel obstruction

  • Gradually increasing abdominal pain with longer intervals between episodes of pain, abdominal distention, obstipation, less vomiting (feculent), more common in the elderly
  • Febrile, tachycardia → shock
  • Dehydration + electrolyte imbalances
  • MCC: cancer, strictures, hernias, volvulus, and fecal impaction
  • KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon

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

Air fluid levels in the abdomen

Dilated loops of bowel and air-fluid levels in the abdomen

Treatment: Bowel rest, NG tube placement, surgery as directed by the underlying cause

Patient will present as →  a 61-year-old healthy man who undergoes a screening colonoscopy. He exercises daily, does not use tobacco, bloody or dark stools, changes in stool, abdominal pain, or fatigue. His prior colonoscopy 10 years ago was normal. During today’s colonoscopy, his gastroenterologist notes a small pedunculated growth in the descending colon.

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 a 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
Acute and chronic pancreatitis (Prev Lesson)
(Next Lesson) Brian Wallace PA-C Podcast: The Bowel Part 2
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