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) Umbilical pain → then pain over McBurney’s point (RLQ)

  • Most common etiology: Fecalith
  • As the inflammation increases, the pain tends to move downward
  • There is usually a marked reduction in or total absence of appetite, often associated with nausea, and occasionally, vomiting and low grade fever.

Signs:

DX: appy ultrasound or Abdominal CT scan

Treatment: Appendectomy

Celiac disease Small bowel inflammation from allergy to gluten

  • Symptoms usually occur following ingestion of gluten-containing food. Also, has extraintestinal manifestations.

Diagnosis:

  • IgA anti-endomysial and anti-tissue transglutaminase antibodies
  • Small bowel biopsy is gold standard

Treatment: Lifelong gluten free diet

Intussusception (ReelDx) 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

Small bowel obstruction
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

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

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 underlying cause

Polyps 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
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