PANCE Gastroenterology and Nutrition PEARLS | NCCPA Content Blueprint

• 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

Infectious:

• 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.

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

Diseases of the Gallbladder (PEARLS)

The NCCPA™ Gastroenterology and Nutrition PANCE and PANRE Content Blueprint covers 3 topics associated with the gallbladder

Disorders of the Liver (PEARLS)

The NCCPA™ Gastroenterology and Nutrition Content Blueprint covers 3 topics under the category disorders of the liver

• Hepatitis D only occurs with hepatitis B
• Hepatitis E + mother = high infant mortality

Hepatitis B Serology

Hepatitis C Serology

Hepatitis A Serology

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

Disorders of the Pancreas (PEARLS)

The NCCPA™ Gastroenterology and Nutrition Content Blueprint covers 2 topics under disorders of the pancreas

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)

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

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

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

Disorders of the Anus and Rectum (PEARLS)

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

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

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

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.

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

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)

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