PANCE Blueprint GI and Nutrition (10%)

Disorders of the Stomach (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE and PANRE Content Blueprint covers 5 topics under the category disorders of the stomach

Gastroesophageal reflux disease 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
Gastritis Dyspepsia and abdominal pain are common indicators of gastritis

Three causes:

1. Autoimmune or hypersensitivity reaction (e.g. pernicious anemia)

  • Location: Body of fundus
  • Pernicious anemia: + schilling test + ↓ intrinsic factor and parietal cell antibodies

2. Infection - H. pylori (most common)

  • Location: Antrum and body
  • Studies: Urea breath test or fecal antigen.
  • Treatment: PPI (Ie. Omeprazole) + clarithromycin + amoxicillin +/- metronidazole

3. Inflammation of 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
Neoplasms Abdominal pain and unexplained weight loss are most common symptoms along with reduced appetite, anorexia, dyspepsia, early satiety, nausea and vomiting, anemia, melena, guaiac-positive stool.

  • Gastric adenocarcinoma in most cases worldwide
  • Virchow's node (Supraclavicular) (view image)
  • Sister Mary Joseph's node (Umbilical) (view image)
Peptic ulcer disease Etiology: 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
Pyloric stenosis Projectile vomiting occurs 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”
  • Labs: Hypochloremic, hypokalemic metabolic alkalosis  (secondary to dehydration) 
  • Treatment: surgical correction - Pyloromyotomy (Ramstedt's procedure) 
Acute Abdomen is a general term used to describe any patient condition that involves sudden onset and severe abdominal pain. There are many conditions that may or may not require emergent surgery to treat, which is why it is important to be able to quickly identify the cause. It can be helpful to sort the causes of acute abdomen into the classically defined region of abdominal pain. Pain can manifest in any location in cases of bowel obstruction, peritonitis, mesenteric ischemia, and strangulation.
IM_MED_Acute_Abdomen_Differential_Diagosis_Upper_Quadrants_v1.3 The causes within the right upper quadrant (RUQ) include cholecystitis, biliary colic, cholangitis, perforated duodenal ulcer, and acute hepatitis. The causes within the left upper quadrant (LUQ)  include splenic rupture and irritable bowel syndrome in conjunction with splenic flexure syndrome.

Acute Abdomen Differential Diagnosis: Upper Quadrants Picmonic

IM_MED_Midepigastrium_V1.3 Midepigastric pain can be due to pancreatitis, aortic dissection, peptic ulcer disease, and myocardial infarction.

Acute Abdomen Differential Diagnosis: Midepigastrium and Diffuse Picmonic

IM_MED_Acute_Abdomen_Differential_Diagosis_Lower_Quadrants_v1.2 Causes within the lower quadrants include ovarian torsion, ectopic pregnancy, pyelonephritis, renal calculi and acute salpingitis. Appendicitis is most commonly associated with right lower quadrant (RLQ) pain, and causes within the left lower quadrant (LLQ) include sigmoid volvulus and sigmoid diverticulitis.

Acute Abdomen Differential Diagnosis: Lower Quadrants Picmonic

Esophageal varices (ReelDx) (Prev Lesson)
(Next Lesson) Gastroesophageal reflux disease (GERD)
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