PANCE Gastroenterology and Nutrition PEARLS | NCCPA Content Blueprint

PANCE Gastroenterology and Nutrition PEARLS | NCCPA Content Blueprint


  1. 6 types of Diseases of the Esophagus
  2. 5 types of Disorders of the Stomach
  3. 3 types of Diseases of the Gallbladder
  4. 3 types of Disorders of the Liver
  5. 2 types of Disorders of the Pancreas
  6. 13 types of Diseases of the Small Intestine and Colon
  7. 5 types of Disorders of the Anus and Rectum
  8. Hernias, Infectious and Noninfectious diarrhea, Vitamin and nutritional deficiencies and Metabolic Disorders

Total: 41 conditions

GU Blueprint Course

Diseases of the Esophagus (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE and PANRE Content Blueprint covers 6 topics under category esophageal disorders
Esophagitis (ReelDx) Non-infectious

  • 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


  • Fungal: Infectious Candida: linear yellow-white plaques with odynophagia or pain on swallowing. Tx with Fluconazole 100 mg PO daily.
  • Viral: HSV: Small, deep ulcers Tx with Acyclovir.  CMV: Large superficial shallow ulcers. Common in HIV
  • EBV, Mycobacterium tuberculosis, and Mycobacterium avium intracellulare are additional infectious causes.
Motility disorders Achalasia: Bird/Parrot beak on barium swallow

Diffuse Esophageal Spasm: Corkscrew appearance on barium swallow

Neurogenic dysphagia: Dysphagia to liquids and solids

Zenker diverticulum: Causes regurgitation of undigested food and liquid into the pharynx several hours after eating

Scleroderma esophagus: Dysphagia to both solids and liquids

Esophageal stenosis: Dysphagia to solids

Mallory Weiss tear History of alcohol intake and an episode of vomiting with blood, upper endoscopy showing superficial longitudinal mucosal erosions.
Esophageal Neoplasms Progressive dysphagia to solid foods along with weight loss, reflux and hematemesis, squamous cell m/c worldwide and adenocarcinoma common in US, complication of Barrett's esophagus (screen barrett's patients every 3-5 years with endoscopy), affects distal esophagus,
Esophageal strictures Solid food dysphagia in a patient with a history of GERD,  Plummer-Vinson: esophageal webs + dysphagia + iron deficiency anemia, DX with barium swallow, treat with endoscopic dilation
Esophageal varices (ReelDx) Typically a complication of cirrhosis, treat with endoscopic banding and IV octreotide, prevent with nonselective beta blockers

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 Barrett's esophagus, PH Probe is gold standard for diagnosis
Gastritis NSAIDs and Alcohol, Endoscopy with biopsy is gold standard for diagnosis
Neoplasms Adenocarcinoma, Virchow's node (Supraclavicular), Sister Mary Joseph's node (Umbilical)
Peptic ulcer disease H Pylori, triple therapy CAP - Clarithromycin, Amoxicillin, PPI
Pyloric stenosis Projectile vomiting occurs shortly after feeding in an infant < 3 mo old, palpable "olive-like" mass

Diseases of the Gallbladder (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE and PANRE Content Blueprint covers 3 topics associated with the gallbladder
Acute and chronic cholecystitis (+) Murphy's sign (RUQ pain with GB palpation on inspiration), after high fat meal, fat-forty and fertile, diagnose with ultrasound, porcelain gallbladder = chronic cholecystitis
Cholangitis fever + jaundice + right upper abdominal pain (Charcot's triad), aggressive care and emergent removal of stones, cipro + metronidazole
Cholelithiasis precursor to cholecystitis, cholesterol stones account for > 85% of gallstones in the Western world

Disorders of the Liver (PEARLS)

The NCCPA™ Gastroenterology and Nutrition Content Blueprint covers 3 topics under the category disorders of the liver
Acute and chronic hepatitis
  • Hepatitis D only occurs with hepatitis B
  • Hepatitis E + mother = high infant mortality

Hepatitis B Serology

Hepatitis Serology      
Anti-HBc IgM Anti-HBc IgG HBsAG Anti-HBs Interpretation
+ - + - Acute HBV
- - + - Early acute HBV
- + - + Resolved acute HBV
- - - + HBV vaccine/Immunity
- - - - No infection or immunity
- + + - Chronic HBV

Hepatitis C Serology

Acute Hepatitis C + ±
Resolved Hepatitis C - ±
Chronic Hepatitis C + +

Hepatitis A Serology

Acute Hepatitis A +
Past exposure - +


Cirrhosis (ReelDx) Chronic hepatitis most common cause of cirrhosis

Skin changes: spider angiomata, palmar erythema, jaundice, scleral icterus, ecchymoses, caput medusae, hyperpigmentation

Labs: typically AST > ALT, ↑ risk for hepatocellular carcinoma: monitor AFP, Hepatic vein thrombosis: Budd Chiari: triad of abdominal pain, ascites and hepatomegaly

Liver neoplasms (ReelDx) Abdominal pain, weight loss, right upper quadrant mass, Hepatitis B and C will increase the risk of hepatocellular carcinoma, ↑ alpha-fetoprotein and abnormal liver imaging

Disorders of the Pancreas (PEARLS)

The NCCPA™ Gastroenterology and Nutrition Content Blueprint covers 2 topics under disorders of the pancreas
Acute and chronic pancreatitis Acute Pancreatitis - epigastric abdominal pain with radiation to the back , Grey Turner sign ( bilateral bruising of the flanks),

Chronic Pancreatitis - classic triad of pancreatic calcification, steatorrhea, and diabetes mellitus, pancreatic pseudocyst (a circumscribed collection of fluid rich in pancreatic enzymes, blood, and necrotic tissue)

Pancreatic neoplasms (ReelDx) Painless jaundice is pathognomonic, likely ductal adenocarcinoma at head of pancreas, Courvoisier's sign - non tender, palpable gallbladder, Virchow's node (or signal node) is a lymph node in the left supraclavicular fossa (the area above the left clavicle)

Diseases of the Small Intestine and Colon (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE and PANRE Content Blueprint covers 13 topics under the category diseases of the small intestine and colon
Appendicitis (ReelDx) RLQ pain, + Obturator and Psoas sign
Celiac disease Symptoms usually occur following ingestion of gluten containing food. Also has extraintestinal manifestations.
Constipation (ReelDx) Defined as less than 2 bowel movements per week
Diverticular disease LLQ pain, tenderness and abdominal distention
Inflammatory bowel disease Ulcerative Colitis is isolated to the colon, lead pipe appearance and continuous inflammation

Crohn's disease from mouth to anus, skip lesions and cobblestoning, strictures = string sign

Intussusception (ReelDx) Sudden onset of acute pain, currant jelly stoolssausage like mass in the abdomen
Irritable bowel syndrome Frequent bouts of constipation alternating with diarrhea, pain relieved with defecation
Ischemic bowel disease Recurrent cramping with postprandial pain in a patient with a history of PVD
Lactose intolerance Hydrogen breath test
Colon cancer Apple core lesion on barium enema, adenoma most common type, treat with resection and 5FU

Screening with colonoscopy begins at 50

  • Fecal occult blood testing - annually after age 50
  • Flexible sigmoidoscopy - every 5 years with FOB testing
  • Colonoscopy - every 10 years
  • Sometimes CT colonography
Small bowel obstruction Look for vomiting, severe abdominal distensions and high pitched or lack of bowel sounds. KUB shows dilated loops of bowel with air fluid levels with little or no gas in the colon.
Polyps Follow up screening in 3-5 years after removal
Toxic megacolon KUB shows dilated colon > 6 cm

Disorders of the Anus and Rectum (PEARLS)

The NCCPA™ Gastroenterology and Nutrition Content Blueprint covers 5 topics under the category disorders of rectum
Anal fissure (ReelDx) Rectal pain and bleeding which occurs with or shortly after defecation, lasts for several hours, and subsides until the next bowel movement.
Rectal Abscess and Fistula Painful; perianal swelling, redness, and tenderness, I&D + high fiber diet
Fecal Impaction Belly cramping and bloating, stool leakage and rectal discomfort in an elderly bed-bound patient, treat with manual disimpaction digitally, followed by a saline or tepid water enema
Hemorrhoids Internal: bright red blood per rectum, pruritus and rectal discomfort

External: significant pain, but no bleeding, treat with excision for thrombosed external hemorrhoids

Anorectal cancer Rectal bleeding + tenesmus (a feeling of incomplete emptying after a bowel movement), the most common anorectal cancer is adenocarcinoma

  • Whenever rectal bleeding occurs, even in patients with obvious hemorrhoids or known diverticular disease, coexisting cancer must be ruled out
Hernias (ReelDx) 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


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. 
    • Remember: Indirect goes through the Internal Inguinal Ring (an “I” for an “I”)
  • Direct Inguinal Hernia: Passage of intestine through the external inguinal ring at Hesselbach triangle, rarely enters the scrotum
  • Hernia often presents on standing and disappears and/or is reducible when patient is supine.

→ Strangulated hernia: A hernia becomes strangulated when the blood supply of its contents is seriously impaired.

→ Obstructed hernia: 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: A hernia so occluded that it cannot be returned by manipulation, it may or may not become strangulated.

Infectious and Noninfectious Diarrhea (ReelDx) Causes of diarrhea may be infectious, toxic, dietary (excessive laxative use) or other GI disease

Inflammatory diarrhea (bloody diarrhea with fever) indicates an invasive organism or inflammatory bowel disease.

  • 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 day care center: Rotavirus
  • Diarrhea on a Carnival Cruise Ship: Norovirus
  • Diarrhea after drinking (not so) fresh mountain stream water: Giardia lamblia
    • Giardia infection incubates for 1-3 weeks, causes foul smelling bulky stool and may wax and wane over weeks before resolving
Vitamin and Nutritional Deficiencies (ReelDx) Marasmus is inadequate intake of ALL energy forms (including protein)

Kwashiorkor is inadequate intake of protein energy and may lead to edema

Fat Soluble Vitamins (ADEK)

  • Vitamin A: night blindness - is an important component in retinal rods and cones and is essential for normal vision, deficiency causes night blindness
  • Vitamin D: rickets, osteomalacia
  • Vitamin E: neuropathy, ataxia - an antioxidant and free radical scavenger, deficiency results in neuronal degeneration with manifests as areflexia and gait disturbances
  • Vitamin K: bleeding (makes clotting factors causes increase in PT/INR)
Vitamin Symptoms At-risk Groups
B1 Thiamine Beriberi Alcoholism
B2 Riboflavin Glossitis N/A
Niacin Pellagra, diarrhea Poverty, alcoholism
B6 pyridoxine Anemia Alcoholism
B12 and Folate Anemia (macrocytic) Alcoholism, elderly and vegans
Vitamin C Scurvy, fatigue, impaired wound healing, Vitamin C is necessary for biosynthesis of collagen, carnitine, bile acids and norepinephrine. Alcoholism and elderly men due to dietary inadequacy
Metabolic Disorders – Phenylketonuria Phenylketonuria (PKU) is an autosomal recessive disorder and inborn error of metabolism involving impaired metabolism of phenylalanine, one of the amino acids.

Phenylketonuria is caused by 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.

Screen infants between 24 hours and 3 weeks

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