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MedStudy Internal Medicine Review Core Curriculum 17th Edition [ALL] - Internal Medicine Medbook4u. ABIM: For over 20 years, MedStudy has excelled in determining and teaching what a clinically competent. Internal Medicine physician should know. Download as PDF, TXT or read online from Scribd. Flag for CME credits for the I 61h Edition Internal Medicine Review Core Curriculum will be available until.
They are. Specificity Figure I If the patient is higher-risk smoker, family history, etc. It presents with anxiety and tremulousness. Small cell carcinoma. Also recognize that naloxone is typically not the correct answer if a scenario presents a patient with dilated pupils. After one half-life.
Pressure ulcers occur most commonly on the heels, trochanter, sacrum, and iliac crest. The main etiology is sustained pressure over a prominent bone.
Shearing and. Know that use of. Stage I is nonblanching erythema reddish maCLtles. Stage 2 is partial-thickness skin loss small superficial ulcer. Do a syncope workup if the patient does not remember the fall or if the history is suggestive. In established ulcers, keep pressure off the area; and if an eschar exists, remove it for proper staging. Then determine whether any arterial or venous insufficiency exists, treat infection if present, and maintain a "clean" ulcer.
Immobility Patients adapt to bedrest; and the longer a patient is immobilized, the harder it is to ambulate again. Give antibiotics, in addition to local wound care, if the patient is systemically ill.
Use deep wound cultures to guide your choice. FSH and LH also decline but disproportionately compared to the more drastic decline in testosterone. For these patients. CD4 T cells increases with age. These [Know: The elderly are very sensitive to drugs for the following reasons: Avoid long half-life narcotics in treating geriatric pain.
With narcotic dependence. Many do not divulge this information unless you ask directly. Slowly taper following these general principles: General rules for medications in the elderly: This may cause poor sleep and insomnia. Stage I and 2 ulcers heal quickly. TSH increases and go slow. The average age of menopause is Many other hormones are normal in the amount produced but do not function as well. Growth hormone reduction appears to be compared to muscle. Sometimes this is feasible. These are the most common causes of falls in nursing homes.
As discussed in the section on osteoporosis. Also avoid pioglitazone in the elderly. Patients with Paget disease have focal areas of marked Metformin should not be given to patients with increased uptake. Testosterone promotes red cell proliferation and diabetes get the same micro. Rosiglitazone is no longer recommended by the ADA.
The most likely causes of hypoglycemia are more often presents as cognitive vitamin D.
Diagnosis is strongly suggested by bone scan results. If the patient has any risk factors for vitamin D deficiency especially poor diet or lack of sun exposure. Decreased mentation Drugs used: Bisphosphonates etidronate. The bones are more brittle. Remember to adjust the insulin doses downward. Elderly patients with toms. Men receiving testosterone cations as younger patients.
The collection of the above. The jury is still out on whether these drugs are associated with an increased risk of cardiac events and stroke. Do not screen elderly men and do with a slight increase in fasting glucose. Glyburide has about twice the incidence versial for prevention of osteoporosis. Vitamin D deficiency is common because of decreased Hypoglycemia intake. Assess the estimated glomerular filtrate rate eGFR prior to use of Osteoporosis The majority of women osteoporosis.
It is a common problem in the elderly. Physical seizures. Any patient who and gallbladder disease. Calendars and orienting signs. Unopposed estrogen use is not delirious should be thoroughly evaluated for a serious associated with the heart disease or breast cancer risks.
Common precipitating causes of delirium include drugs. But older women do. Prior to this study. Know that physical restraints and bladder catheters can incite delirium as well. Acute discontinuation of alcohol.
H2 receptor blockers. Perimenopausal use of estrogen replacement is discussed later in Office Gynecology on page I Pharmacologic treatment of delirium in the elderly is tough because the meds themselves can worsen the confusion.
Sundowning fractures. Be aware especially of meperidine. It is not associated with a precipitating Treatment of delirium is supportive with focus on diagnosis and treatment of the underlying cause. John's wort and valerian root.. Main features are: It is also necessary to minimize daily stress. In the post-op period. Work up the central nervous system imaging estrogen-progestin in women with a uterus is not The important concept: Do not give women becomes illness that may be associated with confusion e.
Premature ovarian failure menopause before age 40 can be safely treated with combination HRT until the woman is 50 years old. The WHI data. Both groups have an increased incidence of gallbladder disease. With sundowning. Combined opioids to manage postoperative pain is not associated with increased rates of delirium. Low-dose haloperidol is an option.
Combination HRT is associated with an increase in Know that in the elderly. What are some options for drug therapy. Treatment of LBD with neuroleptics may bring on a paradoxical psychosis and worsening of parkinsonism. Remember to avoid physical restraint of geriatric patients at all costs because it precipitates delirium and causes falls. Cis in patients with Parkinson's. Cis may be particularly useful in controlling behavioral problems make patients more confused and drowsy. Do not use BDZs in delirious patients because they do not help patients with Huntington disease.
Know that the benefit from treating Alzheimer's is greatest early in the disease. Book 5. CI side effects often involve the GI tract nausea. Dementia is a common development in patients with Parkinson disease as well.
Best results When do patients derive the greatest benefit from Alzheimer treatment?
The evidence-based review found little benefit for any of the current cholinesterase inhibitors or memantine. See Neurology. The same may occur with use of dopaminergic agents. How is dementia different from delirium? Preventive Services Task Force on screening for dementia is that there is insufficient evidence to recommend for or against it.
Patients with dementia have a progressive deterioration In March of cognition that is insidious and chronic-but without altered consciousness.
Vitamin E is no longer recommended as a supplement because it may increase the risk of heart disease and death. Most patients in the U. Lewy body dementia LBD is marked by progressive cognitive decline with concomitant hallucinations. The combination of cholinesterase inhibitor plus tions are always the best choices.
The cognitive impairment presents as: Cis provide a small benefit and help some patients carry out their activities of daily living ADLs.
Dementia acetylcholine has been reported. Ginkgo biloba extract and vitamins A and D have not been shown in clinical trials to improve cognition in elderly patients. Alternative drugs include the 24 points on the risperidone.
A couple of ways to tell the difference: Depressed patients often present complaining of memory loss. These drugs have fewer short-term side effects but have been associated with increased mortality with long-term use.
Notes Drug of Choice Caution! May cause anxiety. Pure SSRls are not likely to increase blood pressure.. Note 1: Most anticholinergic of receptor increases Sexual dysfunction.. Note 2: Elderly patients are especially susceptible to bad patient's depression can help their comorbidities improve outcomes from sleep drugs. Depression is the most common mental problem in the elderly. A host of substances and drugs can potentiate depression. These patients simply have short-duration sleep. See Table I Treatment is usually psychotherapy combined stopped or started meds.
Untreated thyroid disease. It is particularly likely to occur in those who live Insomnia. Get in the bed only when you're sleepy. Pay special attention to the elderly man with depressed mood.
But they have the frequency of awakenings. What is the role of benzodiazepines in treatment of insomnia? Depression-associated delusions are more common in the elderly than in the general population. Medications specifically associated with insomnia include corticosteroids.
What are common side effects of fatigue. No bright lights or TV. Eat dinner or an evening snack to prevent bedtime hunger. Exercise helps. Watch for the side effects potential restless sleep hygiene: Know that treating a Set a schedule for sleep and stick to it. When you're rested. Selective increase slowly with the goal of eventually reaching the diagnose managed comorbidities.
Always check that there is a recent assessment of thyroid function. Exercise during the day. Dopamine agonists generally are the drugs of warming.
The following expert panel treatment recommendations are based on whether the RLS is intermittent. Low-potency opioids generally avoided. Always check a ferritin level to rule out iron deficiency even if the patient does not have anemia.
Try non-pharmacologic therapy first: Diagnosis is made based on clinical history. Because of this. Multisensory deficits: Think about multisensory deficits as a cause for disequilibrium in the patient with a mix of visual. Symptoms are worse in the evening and at night. The FDA required reduced recommended doses for zolpidem products in because of persistent impairment the next morning.
Be careful -may cause augmentation worsened symptoms or rebound. Make sure that the patient's complaints aren't actually akathisia from medications phenothiazines and SSRJs. Dizziness that sounds like presyncope or "faintness" should be taken seriously and evaluated with a cardiovascular workup.
The melatonin agonist. RLS can be primary or caused by other conditions: Multisensory deficits vestibular than in other patient groups. Treat this by maximizing support for each sensory impairment and providing assistance devices e. It is a then eventually resolves good choice for the elderly. Try non-pharmacologic first.
Their cost can be prohibitive. When any patient complains of "dizziness. Try gabapentin. In geriatric patients. In these cases. It increases the risk of myocardial non-benzodiazepine sleep agents?
In the elderly. No drugs are used to treat BPV. BPV can be diagnosed by the 80 years. Digoxin is indicated only for more severe Treatment of BPV can be accomplished through one of heart failure and reduces hospitalizations. This maneuver involves turning the charged from hospital.
Around these patients. Epley and Semont. Hearing aids can help they may have developed it as an aging adult. Low What cause of dizziness is associated with diastolic pressures have been associated with increased improvement when the patient holds onto a cardiovascular events.
The incidence of congestive heart failure CHF in the elderly is increasing dramatically and is now the number I cause of hospitalizations in this group. Be sure Elderly patients with asthma may have long-standing to check for cerumen impaction. A positive test is visible nystagmus in either the recumbent or the upright position. Mortality benefit has been shown for ACE inhibitors. The most common cause is presbycusis. Spironolactone can be a useful adjunct that can also lower mortality for systolic heart failure.
Several studies show these patients benefit from treatment. It is bilateral. Avoid Rheumatology. Number 2 is pneumonia. See polymyalgia rheumatica are also present e. The systolic heart failure. Decreased hearing is an age-related condition. Group Dix-Hallpike test.
Treat CHF itself primarily with diet. Repeat the maneuver with the head turned in the opposite direction. If you use spironolactone. Bronchoprovocation is used to diagnose asthma in patients with normal spirometry. Urinary incontinence. Know that reversible obstruction is consistent with asthma.
Normal micturition is dependent on an intact neurologic air pollution. Urge incontinence UI is a common cause of geriatric incontinence. UI is related to overactive bladder. Risks for development of adult-onset asthma are the same as for younger patients: Book 2. This is due to the fact that this criterion contractility or "outflow" problem outlet obstruction is not as specific in this age group and overdiagnoses or incompetence. Know that apnea that results in poor sleep and excessive daytime somnolence carries a higher rate of morbidity in patients who are frail and already prone to falls.
A response to bronchodilators incontinence: Always consider the possibility that the patient has a serious underlying condition responsible for the leakage. With urge incontinence. It is a urologic condition defined by Management of geriatric asthma is the same as for the urgent need to void frequently and during the younger patients.
Diagnosis and management is the same as in younger patients. Definitive diagnosis is made with spirometry. With SUI. Bladder training and Kegel only! Stress urinary incontinence SUI is second in frequency in geriatric women. Remember that anticholinergics can precipitate acute angle glaucoma! Review Also. Surgery has Is urinary incontinence considered a normal consequence of aging?
Bladder training and Kegel exercises: Treat underlying cause if when there is an increase in intra-abdominal pressure possible.. SUI is associated with multiple garments. The true etiology is unknown. The goal is to eventually delay voiding to every 4 hours with no interval leakage. As the bladder loses the modulating influence from the brain. Once the urge is controlled. They have other anticholinergic side effects e. Incomplete Emptying Incomplete bladder emptying is sometimes still called Treatment is best accomplished with behavioral therapy.
What is the best initial treatment for stress urinary incontinence? Pelvic muscle exercises Kegel's are also helpful for UI. Periurethral collagen injections are an option for those What are the 4 types of incontinence?
Bladder training and Kegel's help these patients. What are the GOLD recommendations for diagnosis of asthma in the elderly? Note that some women with urinary incontinence have a mixture of SUI and urge incontinence. Psychogenic retention can also be a cause. Anticholinergic drugs are the most Bladder training is more effective than the more commonly common causes of drug-induced incomplete emptying.
What is the role of bladder catheterization in the treatment of geriatric incontinence? Mixed Incontinence V d ti e n U Mixed incontinence. Stress incontinence is initially best treated with behavioral therapy. The outlet obstruction causes a distended bladder and high-volume. We still do not understand what causes BPH and have yet to identify any specific risk factors-except age.. A 5-alpha-reductase inhibitor finasteride.
The organic causes are neurogenic. This cGMP causes the relaxation of the smooth muscle in the penis. Treatment The smooth muscle in the flaccid penis is in a o Neurogenic: Usual cause is diabetes. Other causes are surgical procedures especially prostate. Of the alpha-blockers. Certainly ficient for satisfactory sexual intercourse.
Treatment is disimpaction and subsequent bulking agents. The swelling of this tissue causes with intake of caffeine and alcohol diuretics. Know that these drugs decrease serum PSA. BPH does not increase the chance of prostate cancer. Be careful with combining sildenafil or vardenafil with these drugs because the combination worsens hypotension. Other causes are surgical procedures. Make sure patients know to reduce t increases the inflow through the helicine artery into the erectile tissue.
Generally start with alpha-blockers terazosin. These can be grouped as follows: Usually slow onset. Most common side effects of these meds are orthostasis and dizziness. ED that occurs other diseases can cause these symptoms e. In elderly men. Typical presentation is an elderly person with complaints of diarrhea and abdominal discomfort and who has hard stool in the rectal vault on physical exam.
Most causes of ED are at least partially organic. These drugs work better for large prostates and have a more durable effect. I a digital rectal exam to palpate the prostate and assess for irregularities and increased size.
Loss of nocturnal and morning erections. It is not ED. ED is directly correlated with depression. There is a risk of hearing loss with all of the ED? PDES inhibitors. It has is on no medications. This drug is approved for daily use. Side effects are due to its vasodilatory The properties-headaches. Tissue erosion may occur.
Uroselective alpha-blockers medications are commonly used for treatment? Usually used only for those who have failed all other therapy. Symptoms may include gradual onset of frontal headaches or visual disturbances space-occupying Alprostadil prostaglandin EI injected into the corpora tumor.
Which medications most commonly cause ED? Scarring may cause erections to curve. Relative contraindications are CHF. Complications are associated with the surgery. They and flexible rods. Erectile function may be improved for up to 36 hours. Contraindications are any concurrent nitrates. I Beneficence: One specific side effect is back pain.
If an exam presents a young male with ED who Yohimbine is a naturally occurring alpha-blocker. This is the usual cause for ED in younger patients. They continue to have nocturnal and morning erections. Better than placebo but much less effective than sildenafil. Penile implants: Various types-hydraulic. If there are no complications.
ED due to vascular compromise indicates increased risk of present and or the patient prefers them to oral therapy. Many others also cause ED. Reports of hearing loss have also been documented. It is especially useful 3rd line treatment for ED: Normal aging: Sexual potency does decrease with age. SSRis used for depression treatment are also associated with a very high incidence of h ta sexual dysfunction generally delayed ejaculation.
What is the initial treatment for BPH? What doxazosin. Examples are anxiety. The advanced The physician's own recommendations based on best clinical judgment but the information in the chart belongs to the patient. Patients should be an active part of the decision-making process. If he comes into the emergency department and requires intubation to survive-and states that he Know that physicians are responsible for providing honest information on disability claim forms and should not attempt to assist a patient in obtaining disability benefits erroneously.
It is absolutely unethical for physicians to have any sexual relationship with a current patient. Most decisions on patient care are carried out without need for competency hearings. Know that physicians are responsible for caring for 9 9 If requested. A lawyer is not needed to make a living will. Decision-making capacity is determined by the physician and at times may be difficult to determine.
The physician must give the patient written notice of intent and must request approval from the patient for transfer of medical records to the accepting physician. V d ti e n U Patients require informed consent. If this process is not followed. Even former patients can cause ethical problems. There are many transitory or reversible conditions that can interfere with this capacity.
Constraint of a person's free choices is permissible only when these choices infringe on another person's rights and welfare. Use of social media has added a new dimension to interactions with patients.
It is assumed that the physician takes appropriate infection control precautions. The ethics document from the Federation of State Medical Boards says that physicians cannot even have sexual relationships with the relatives of existing patients.
Competency refers to the legal determination of one's decision-making capacity. Know that fluids and nutrition are ethically regarded as the same as other forms of treatment. Good end-of-life care entails treatment based on many issues. Organ donation decisions should be broached at the appropriate time with decision makers by organ procurement specialists who are separate from prospective donors' health care providers in order to avoid conflicts of interest or a perception of conflicts of interest.
The "contract for health physician supplies the means of death to a patient. Welfare considerations include suffering. If the surrogate has no knowledge of the patient's wishes. What should you do? The downside of pain medications is that they can cause V d ti e n U confusion and a decreased ability to communicate. His family does not want anything patients in pain are in a special situation. Terminal G R intubation. For instance. Health care providers of prospective recipients should not be providing care to prospective donors for similar reasons.
The surrogate's authority ends when the patient dies i. Another option is for the subject to give someone 9 9 durable power of attorney. The waxing and waning associated with certain conditions. The assistance of hospice workers in this situation can be very helpful. Know that respecting a patient's choice to refuse life-sustaining treatment is different from either of these. In some states. The lengthier questions help you integrate content on a subject with additional clinical information to better simulate a real-life patient scenario.
This helps you recognize disease states and associated treatment, which is a skill heavily tested on Board exams. Some selected patient case scenarios may appear more than once with only slight variations, with the associated questions addressing different diagnoses and treatment aspects of the case.
This is in keeping with the approach Board questions take in limiting patient case assessments to one key testing point. There is a popular misconception that members of organizations perceived to be associated with medical boards write Board exam questions; e.
Not only is this not true, it is actually forbidden for anyone to write formal Board exam questions if they work for a company or organization in the business of producing Board preparation materials. This would compromise the integrity of the examining process. MedStudy is proud to be able to bring you Board-style questions and answers of the highest quality—to offer you education that is relevant in a format that reinforces your knowledge to prepare you well for whatever challenge the ABIM Board exam presents to you.
One inal note: Even the best question-and-answer exercise by itself is not an adequate preparation for a Board exam. C Answer: Perform endoscopy. This patient presents with symptoms characteristic of GERD for the last 3 months. This patient has anemia noted on his laboratory studies. The next best step would be upper endoscopy. Had alarm symptoms been absent, an empiric trial with a PPI would be appropriate.
An ambulatory pH study would be indicated in patients with GERD who do not respond to empiric therapy. Testing for H. Tissue transglutaminase IgA Ab would be indicated to evaluate for celiac disease.
Manifestations of celiac disease can include abdominal pain and anemia. However, celiac disease should present with signs of malabsorption, which this patient does not have. Board Testing Point: Recognize alarm symptoms that warrant endoscopic evaluation in patients with GERD. A Answer: The patient needs more than just medication or reassurance at this point, though the workup is still likely to be negative.
EGD is the correct answer. Recognize the alarm signals in GERD. D Answer: Serum lipase. His physical exam reveals Cullen sign, ecchymotic bruising in the periumbilical region that is an uncommon inding associated with pancreatitis.
However, this is not a diagnostic inding. The next best step would be to conirm the diagnosis of acute pancreatitis by an elevated serum lipase or amylase level. A CT of the abdomen should be reserved for cases where the diagnosis remains unclear after initial lab work.
An ultrasound of the abdominal aorta would be used if you suspected an abdominal aneurysm. ERCP would be indicated to treat a patient with conirmed gallstone pancreatitis. CA is a nonspeciic serum test used in the diagnosis of cholangiocarcinoma and has no role in the diagnosis of acute pancreatitis. Identify the clinical and laboratory features to diagnose acute pancreatitis. E Answer: Gallstones are the most common precipitant of acute pancreatitis, but this patient has a history of remote cholecystectomy that makes this answer unlikely.
Tobacco is more commonly associated with chronic pancreatitis rather than acute pancreatitis. Hydrochlorothiazide has been linked with elevations in serum calcium and pancreatitis, but the incidence is much more uncommon compared to alcohol and gallstone pancreatitis. Recall the most common etiologies of acute pancreatitis. He had a recent MI. His use of ASA is not a contraindication nor is his platelet count. Other contraindications for an EGD include an uncooperative or combative patient or an intestinal perforation which requires immediate surgical intervention, not an EGD.
Know the contraindications for EGD. Endoscopic retrograde cholangiopancreatography ERCP with laparoscopic cholecystectomy. Rarely, primary stones will occur in the ducts in the setting of increased pigment or congenital abnormalities. This patient has symptoms of acute cholangitis Charcot triad: Cholangitis is inlammation of the bile ducts usually caused by bacteria and most often occurs when there are gallstones partially obstructing the bile tract.
Many patients with this condition respond rapidly with appropriate supportive measures, including antibiotics. The concern is when a complete obstruction of the ductal system occurs, which can lead to severe illness with resulting SIRS systemic inlammatory response syndrome or septic shock.
The most appropriate diagnostic study for choledocholithiasis gallstones is cholangiography, which usually is accomplished by ERCP with combined laparoscopic cholecystectomy. This reduces the risk of complicated biliary tract disease with the need for choledocholithotomy and T-tube drainage. Ultrasound and MRCP would not be appropriate for an urgent scenario. Liver Bx would not be appropriate. One other pearl from this case: A palpable gallbladder Courvoisier sign would suggest carcinoma of the pancreas.
Know that ERCP with laparoscopic cholecystectomy is the best therapeutic procedure for choledocholithiasis. Esophagogastroduodenoscopy EGD.
She has warning signs: In younger people with gradual onset, most would do barium swallow irst. However, this woman is older and has abrupt-onset dysphagia with weight loss.
MRI of chest is not indicated at this point. Motility studies would be considered if the EGD is unremarkable; or more likely a CT scan of the chest would be the next step after the EGD shows her mass lesion. Recognize the clinical warning signs when EGD would be the best test to work up dysphagia. Achalasia may present at any age but usually occurs between the ages of 50 and Regurgitation while bending is common.
Usually the regurgitation is not associated with heartburn, as is seen with gastroesophageal relux. Chest pain can occur and in some patients can be severe. Treatment is focused at opening the lower esophageal sphincter.
Initially, this can be done with pneumatic dilatation with a large balloon inserted within the LES. Surgical intervention via myotomy is also effective. Botulinum toxin has been used, but has a higher relapse rate. The barium swallow here was quite helpful in that you can see a large dilated esophagus tapering to a beak-like narrowing at the lower end—the classic inding for achalasia. Chagas disease could present this way, but you would need something in the travel history to help you.
Gastroesophageal relux could give you these symptoms, but the barium swallow is classic for achalasia, and would not be seen with relux disease. The CXR is also helpful since this is a classic description for this disease too. Esophageal ulcers more commonly present with retrosternal chest pain, odynophagia, or epigastric pain.
Acute bleeding could be the only symptom. Again, in this patient, ulcer is not likely based on the clinical and x-ray indings. Finally, the Plummer-Vinson syndrome is when you see formation of an anterior web at the upper end of the esophagus; the x-ray indings do not support this syndrome.
Recognize the clinical and radiologic features of achalasia. Progression is likely to occur, and stricture formation with nearly complete loss of peristalsis will be seen in later forms of this disease. This woman has scleroderma. It causes reduced-to- absent lower esophageal sphincter pressure unlike achalasia. The other symptoms and signs that she has go along with the disease. The symptoms will not improve as the disease progresses. H2 blockers may provide some symptom relief but are unlikely to provide complete recovery from this progressive connective tissue disease.
Her skin indings are related to her esophageal disease. The gastrointestinal indings frequently involve other areas besides the esophagus. Recognize the clinical features of scleroderma and the associated gastroenterological manifestations. Pill-induced esophagitis. In adolescents, pill-induced esophagitis is common, especially if they do not take the time to use water to swallow pills. Doxycycline is one of the classic drugs to do this.
Other common drugs associated with this include aspirin, NSAIDs such as ibuprofen, iron pills, potassium supplements, and alendronate for post-menopausal osteoporosis. Scleroderma is very unlikely in a year-old male without other symptoms.
Gastroesophageal relux would not generally cause this type of isolated symptom. Cocaine abuse is not associated with isolated dysphagia. Bulimia could be associated with dysphagia, but he has no other signs or symptoms of this illness. Recognize the clinical characteristics of pill-induced esophagitis. Improvement with therapeutic trial of anti-GERD medication. All of the indings listed except improvement with therapy should prod you to get an EGD fairly quickly.
B Answer: He has severe disease that will likely require long-term medical therapy, so the best option is chronic proton pump inhibitor therapy. The GERD guidelines recommend medical therapy over surgical intervention because of the inherent risks of surgery and the potential for increased side effects such as bloating and GI discomfort after surgery. As he has already shown, non-proton pump inhibitors are not likely to be effective. Omeprazole or another proton pump inhibitor could be used for long-term therapy and is an option.
Know that the latest GERD guidelines recommend medical therapy over surgical intervention because of the inherent risks of surgery and the potential for increased side effects. Refer for surgery. Now that he has high-grade dysplasia, he has 2 options according to the latest guidelines on Barrett esophagus published in The irst option is standard resectional surgery, and the second option is to repeat EGD within 3 months and then follow 3-month EGD surveillance until intervention is needed.
At this stage, decreasing gastric acid concentrations will not reverse the current damage; also, a 1-month time interval will not be useful in looking for changes. Surveillance every 6 months is too long a period of time in between. Monthly EGD is not cost-effective and very impractical. Finally, application of low-grade beam radiation to the affected area is not indicated and would harm the patient.
Know the latest guidelines for management of Barrett esophagus. Since she has known Helicobacter pylori, it is prudent to treat her with appropriate antimicrobial therapy. This is a dificult problem. In the irst place, she never should have taken the test. The problem is what to do with this information. We know that H. Therefore, you would think that further investigation is not indicated or necessary because she is asymptomatic, so no treatment is required.
However, H. Here is the problem: Even though it is very unlikely she will ever develop complications from her H. The testing done today is usually quite speciic and sensitive for the infection, so wasting money on a new test is not likely to be helpful.
She is completely asymptomatic, and we know that most people with H. Know that inding H. Non-invasive testing for Helicobacter pylori. In a healthy young person deined by the American Society of Gastroenterology as being anyone under the age of 45—complain to them if you are over 45!
Non-invasive testing in symptomatic patients and treatment in those with positive results are cost-effective. Barium swallow is a test for dysphagia, not dyspepsia. EGD with biopsy is the most speciic test for diagnosis of H.
On the biopsy specimen, you can actually look for histological evidence of the little critter H. Both are very speciic for infection if present. So remember: Finally, empirical H-2 blocker therapy alone would be ineffective for H.
Know the indications for non-invasive H. A urea breath test is indicated at this point to determine cure. Treatment failure in the remainder of patients usually means that the ulcer will recur. Also, if untreated, these patients are at increased risk of complication such as gastrointestinal hemorrhage.
The urea breath test is the best test to assess cure. A stool antigen test can also be used if the urea breath test is unavailable. Repeating EGD is indicated only in certain instances: Patients cannot be on proton pump inhibitors during breath urea testing because it interferes with the testing. Serologic testing is not effective for follow-up testing and also is no longer recommended for initial diagnosis. Recognize that a urea breath test or other noninvasive test is the best test to follow up and determine cure of H.
Fasting serum gastrin level. Note that his ulcer is in an unusual location; generally, any ulcer past the duodenal bulb should make you think about ZES. Also, he has severe esophagitis, which can be seen in regular ulcers; but the inding of the EGD makes ZES more likely. Additionally, his family history is quite strong, and he has been having diarrhea—another hallmark of this syndrome.
Although diarrhea often occurs concomitantly with acid peptic disease, it may also occur independent of an ulcer. Etiology of the diarrhea is multifactorial, resulting from marked volume overload to the small bowel, pancreatic enzyme inactivation by acid, and damage to the intestinal epithelial surface by acid. Occasionally, you can have mild malabsorption of nutrients and vitamins. The diarrhea may also have a secretory component due to the direct stimulatory effect of gastrin on enterocytes or the co-secretion of additional hormones from the tumor, such as vasoactive intestinal peptide.
Gastric acid hypersecretion is responsible for the signs and symptoms observed in patients with ZES. Other clinical situations that should create suspicion of gastrinoma are ulcers refractory to standard medical therapy, ulcer recurrence after acid-reducing surgery, or ulcers presenting with frank complications bleeding, obstruction, and perforation.
Recognize the clinical features of Zollinger-Ellison syndrome and know that a serum gastrin level is the best screening tool. Alcohol consumption.
Note that alcohol consumption is not a risk factor for gastric carcinoma. All of the other factors listed are associated with increased risk. Also remember that history of gastric ulcer is not associated with increased risk of carcinoma.
Other factors that are associated include diets high in dried, smoked, and salted foods; foods rich in nitrates; Barrett esophagus; and distal gastrectomy. Uranium mining is yet another association…so if they describe someone who is a uranium miner, look for the possibility of gastric carcinoma.
Finally, lower socioeconomic class is associated with increased risk. Know the risk factors for gastric carcinoma. Colonoscopy with upper endoscopy. She has symptoms consistent with Crohn disease.
A colonoscopy with upper endoscopy will conirm disease location and show evidence of intestinal complications. Early in the disease process, the scope will show thickened folds and aphthous ulcerations. Skip lesions are seen in Crohn disease. With her prolonged history and initial negative stool testing, it is not necessary to repeat ova and parasite testing again. An MRI would be helpful if you were concerned about an abscess; but her current symptoms are fairly mild, and no evidence exists for this.
Endoscopic laparotomy is invasive and not indicated at this stage of diagnosis. A rectal biopsy is contraindicated and will not provide any helpful information for Crohn disease. Stop sulfasalazine and use another agent for control of his disease. Sulfasalazine is split into sulfapyridine and mesalamine. The problem is the sulfapyridine can cause reversible infertility in men. The best answer is to stop the sulfasalazine and prescribe another agent or attempt a trial off of therapy, since he has not had a problem in over 5 years.
Formal urologic evaluation is not indicated at this point; we have found that his sperm count is abnormally low, which explains why they are not conceiving. His wife does not need to undergo any testing. Recognize that sulfasalazine may cause reversible infertility in men. Recommend referral to surgery.
Even though he has been doing well until recently, the inding of high-grade dysplasia in lat mucosa indicates that colon cancer is possibly imminent, and removal of his complete colon will be curative.
It is dificult to think about this in someone who has had relatively mild ulcerative colitis. Additionally, if you had found a mass lesion that showed dysplasia, complete colectomy would be indicated.
Once you are at this stage, repeat colonoscopy is not helpful and will just prolong the inevitable. Likewise, reinstituting medical therapy would run the risk of allowing the high-grade dysplasia to progress. Know the recommended colonic follow-up and treatment for patients with ulcerative colitis. No antibiotic therapy. With uncomplicated Salmonella gastroenteritis, antibiotic therapy is not indicated.
If you treated her with antibiotics, you risk prolonging her shedding as well as increasing risk of resistance. Exceptions are the very old, the very young, and the immunocompromised. We treat these special groups with antibiotics because the risk that the Salmonella may disseminate or cause more extensive problems is greater than the risk of prolonged shedding. Know that Salmonella gastroenteritis generally does not require antibiotic therapy.
Give supportive care only. Starting antibiotics in patients with E. H7 actually increases the risk of HUS hemolytic uremic syndrome. Therefore, supportive care is all that is indicated for this patient. Antibiotics are absolutely contraindicated! Know that infection with E. H7 is not treated with antibiotics. Campylobacter jejuni. The other organisms listed in the choices are not associated with this syndrome.
Of note: As in this case, humans can get Campylobacter from their pets, especially dogs; conversely, dogs have become infected from their owners. Phenolphthalein abuse. Note that she has a normal physical examination, and we have spent quite a bit of time and money on diagnostic tests, which all have been negative. The only positive laboratory value is the sodium hydroxide test, which indicates that she is abusing phenolphthalein.
You can also conirm this with speciic urine tests for this agent. The bisacodyl could be conirmed also by urine testing. Irritable bowel syndrome is a diagnosis of exclusion, and we have found another etiology for her symptoms. Carcinoid is a rare cause of diarrhea, but she does not have any of the other symptoms such as lushing, tachycardia, and explosive diarrhea. Colonoscopy and EGD are reserved for the later stage of workup of chronic diarrhea and are not indicated at this point, particularly in light of our indings of phenolphthalein abuse.
Recognize the clinical indings associated with phenolphthalein abuse. Iron deiciency anemia. Remember that iron is almost completely absorbed in the duodenum. With celiac disease, this is one of the main sites of malabsorption. B12 deiciency is very common with tropical sprue, but not celiac sprue.
Folate deiciency is also common but less so than iron deiciency. Celiac disease exacerbation would not be responsible for anemia of this degree with heme-negative stools and no history of blood in the stool. Primary intestinal lymphoma is a rare late complication of celiac sprue—and the key words here are rare and late—so this is not a concern for this year-old leprechaun at this point.
Recognize the association of iron deiciency anemia with celiac disease. Infection with Tropheryma whippeli. This patient has Whipple disease. Posterior uveitis is also seen. His night blindness is due to vitamin A deiciency from malabsorption—hence, the low carotene levels. The clincher was the biopsy of the small intestine and the indings in the lamina propria. Also available from certain labs is a PCR for the organism, which could be used on the biopsy material as well.
Know the clinical manifestations and the organism responsible for Whipple disease. Colonoscopy every 5 years beginning now. A positive family history is the most commonly identiied factor that increases the risk of colorectal cancer. Persons with a single 1st degree relative with colorectal cancer that was diagnosed after age 60 experience a risk of colorectal cancer at age 40 that is equivalent to that of average-risk persons at age Such persons should begin colorectal screening at age 40 options for this: The relatives of these affected patients should begin screening at age 40, or 10 years younger than the youngest affected 1st degree relative, whichever comes irst.
Screening for these patients should be by colonoscopy at 3—5 year intervals depending on the strength of the family history. Know the colorectal screening guidelines for individuals with a family history of colon cancer. Repeat colonoscopy in 10 years. Patients with hyperplastic polyps found on a screening colonoscopy require no further workup.
These are quite common and do not predict increased prevalence of adenomas. CEA level is not indicated at all and is not approved as a screening test.
Recognize that small, hyperplastic polyps confer no increased risk of colon cancer. Repeat colonoscopy in 3—6 months to be sure that resection was complete.
Frequently, these lesions cannot be completely or safely excised during colonoscopy, and the patient should be referred for primary surgical resection. However, in this case, complete excision was possible or thought possible, and it was done at time of colonoscopy. If a residual polyp is present at this point, it should be removed and the completeness of resection documented again within 3—6 months. If 2 or 3 attempts at removing a polyp are not successful, surgical referral is indicated.
Know the guidelines for follow-up of a suspicious sessile polyp. Because the incidence of recurrent cancer is small, no other laboratory or imaging studies are indicated for this patient; follow-up should proceed as with benign adenomas.
He meets all of the favorable prognostic criteria outlined by the American College of Gastroenterology: These patients with favorable prognostic criteria should have follow-up colonoscopy in 3 months to check for residual abnormal tissue at the polypectomy site if the polyp is sessile.
After 1 negative examination, care can revert to standard surveillance as performed for patients with benign adenomas. Because the incidence of recurrent cancer is small, no other follow-up laboratory or imaging studies are indicated. Know the guidelines for follow-up colonoscopy after inding a cancerous polyp.
Start adjuvant chemotherapy without radiation therapy. The spread to the regional lymph nodes is what puts her in that category. Dukes D Stage IV is with distant metastases and requires surgical intervention and expert guidance on whether adjuvant chemotherapy is helpful or not. Know the recommended therapy for colon cancer based on the staging of the colon cancer. Right lower quadrant pain with fever should always raise the suspicion for appendicitis.
The typical presentation of appendicitis is initial peri-umbilical pain, which then localizes to the right lower quadrant. Fever and leukocytosis are also typical of appendicitis. The presentation of appendicitis in the elderly is often atypical. Pain can be poorly localized or even be absent. Fever may not be present.
Leucocytosis is variable. The rate of perforation is high in the elderly because of the delay in making a deinite diagnosis of appendicitis. Appendicitis is still largely a clinical diagnosis. Crohn disease is least likely for several reasons. Crohn disease is more prevalent in Caucasians than in African- Americans or Asians.
It typically presents at an earlier age, with peak incidence at 15 to 35 years of age. The presentation is usually subacute with recurrent episodes of right lower quadrant abdominal pain, low-grade fever, diarrhea, and possibly a right lower quadrant mass.
Acute ileitis, however, may have an abrupt onset with fever, leucocytosis, and abdominal pain. The clinical picture may be indistinguishable from acute appendicitis. Often the inal diagnosis is made at laparotomy, when characteristic indings indicate Crohn disease. Diverticulitis is high on the list of differential diagnoses, especially when the patient has a known history of diverticulosis. Fever, acute onset of abdominal pain, and leucocytosis are consistent with diverticulitis.
However, the location of diverticulitis is typically in the left lower quadrant. In the case of redundant sigmoid colon, however, the pain can be located in the right lower quadrant. Diarrhea is often present in diverticulitis. Colon cancer would not present in this fashion, and her abdominal pain with the CT indings does not support viral gastroenteritis. Recognize the clinical features of acute appendicitis. Abdominal CT scan. She has known history of diverticulitis, and now with the indings of rebound tenderness and involuntary abdominal rigidity, there is the possibility of an abscess or perforation of a diverticulum.
Emergent CT scan or ultrasound should be done to evaluate for this possibility. Colonoscopy and barium enema should be avoided during the active stage. If an abscess is found, drainage is necessary either with radiologic guidance or surgical intervention. Bowel rest is indicated, but you must rule out the possibility of something more severe such as abscess or perforation.
A bleeding scan is not indicated since she has no evidence of a severe bleed. Bright red blood on toilet paper in a year-old man. The year-old man likely has hemorrhoids.
Everyone needs a colonoscopy. Recognize which clinical events would warrant colonoscopy for workup. He has the indings of intestinal angina, also known as chronic mesenteric ischemia.
He has the classic triad: Additionally, he smokes and has evidence of peripheral vascular disease lower extremity indings. He needs an arteriogram to conirm evidence of occlusion in the splanchnic intestinal arteries.
Treatment is with surgical bypass. Recognize the clinical features of chronic mesenteric ischemia. He has now developed Cullen sign, which indicates the possibility of a hemoperitoneum. This means that severe necrotizing pancreatitis has developed. Recognize the clinical signiicance of Cullen sign.
He has acute hepatitis B and past infection with A. He has IgM antibody only to hepatitis B core. He also has IgG to hepatitis A, which means that he has had an old infection from which he recovered. Impossible; remember that chronic A does not exist. Again, impossible. This would be correct if all the antibody studies were negative. Know how to interpret hepatitis serologic tests. Wilson disease. The picture is showing you classic Kayser-Fleischer rings, the yellowish-brown discoloration in the cornea close to the limbus.
It can present in many ways, but a chronic hepatitis-like picture is common. Multiple organs can be involved due to the excess amount of copper.
This is an autosomal recessive disorder of copper metabolism. A mutated copper transporting enzyme prevents the excretion of copper detached from the copper-transporting ceruloplasmin into the bile.
Rising copper levels inhibit ceruloplasmin formation from apo-ceruloplasmin. A marker for this disease is a low ceruloplasmin, but remember that the low ceruloplasmin does not cause the disease process; it is the excess copper. By the way, the Smith-Jones syndrome does not exist. Recognize the clinical features of Wilson disease. Percutaneous endoscopic gastrostomy PEG is appropriate intervention to allow hydration and nutrition. This patient has oropharyngeal dysphagia, of which the most common cause is a CVA.
There are other neurological causes as well, like ALS. The best study for this is the modiied barium swallow. Endoscopy is not helpful at all in determining the reason for this type of dysphagia. PEG is considered a surgical procedure, and antibiotics do reduce the risk of infection afterwards. Other complications would include bowel perforation, bleeding and local cellulitis.
Many patients will still aspirate after the procedure, although this is more commonly due to aspiration of saliva rather than relux and aspiration of gastric contents. Recognize the clinical utility of a percutaneous endoscopic gastrostomy in a patient who has had a recent cerebrovascular event. Omeprazole 20 mg PO, before breakfast. This patient appropriately underwent endoscopy because of his long history of relux symptoms.
Endoscopy is done to make sure there is no presence of Barrett esophagus, which in this case there was not. He does have signiicant esophagitis, and the issue is what type of treatment gives the most complete acid suppression. Proton pump inhibitors are stronger than the H2 receptor antagonist. Treatment is dilation. Image Usually the history is of progression of symptoms: Dysphagia with weight loss represents esophageal malignancy until proven otherwise.
Esophageal cancer Plummer-Vinson Syndrome Plummer-Vinson syndrome, a rare disorder, results in dysphagia due to an upper esophageal web. Patients with Plummer-Vinson syndrome have a slightly increased risk of squamous cell esophageal cancer. Bulbar palsy causes dysphagia due to weakness, whereas pseudobulbar palsy causes dysphagia due to disordered contractions. Any type of dysphagia can cause aspiration. This aspiration is often well tolerated and does not need treatment, unless pulmonary problems arise.
These patients may complain of choking, gagging, and nasal regurgitation. If you suspect aspiration, perform a modified or 3-phase barium swallow to confirm the diagnosis. Tracheostomy does not prevent chronic aspiration. Video swallowing studies are also useful in evaluating neurologic dysfunction. In older patients? The LES is "wide open" with low or no tone or pressure, resulting in severe acid reflux damage to the esophagus.
Dysphagia can be due to any 1 or a combination of the following 3 problems: I Esophagitis 2 Stricture 3 Impaired motility So, workup requires a barium swallow followed by EGD to look for all 3 of these possibilities.
If esophagitis is present, begin aggressive PP! Any stricture can be safely dilated using standard techniques. Polymyositis and dennatomyosit. Its pathogenesis involves interleukin-5 IL-5 in a central role in concert with eotaxin. EoE occurs most commonly in men age years. The "classic" EGD finding is a scalloped appearance with ridges or rings trachealization in the esophagus.
GERD patients may have increased eosinophils as well Image Treatment is difficult. Long-term therapy Image! PPI therapy may be helpful in those with concomitant reflux or PPI-responsive eosinophilic esophagitis. Pill-Induced Esophagitis Pill-induced esophagitis is most likely when pills are taken with little or no water or before lying down.
Ds, iron, bisphosphonates alendronate , and quinidine. The pain can be severe. Diagnosis can be made based solely on history! If the history is typical, with abrupt onset of symptoms and an obvious offending medication, no EGD is needed. Stop the offending medicine and reassure the patient that the condition will improve. Educate your patients to take medications in the upright position with plenty of water. If you see thrush in the mouth, you can assume that the esophagitis is also due to Candida; treat the patient empirically with fluconazole.
If there is no improvement, or you're unsure of the diagnosis, EGD with biopsy is the procedure of choice. Rarely is dilation needed or helpful. Efficacy of the PPis depends on plasma levels. There is a genetic mutation for this enzyme that results in a person being a "slow metabolizer. The proportion of slow metabolizers varies by ethnicity. Slow metabolizers of PPIs have much better results than fast metabolizers. PPis cause hypergastrinemia, achlorhydria, and possibly gastric atrophy.
Short-term and long-term effects of PPIs are becoming known. Community-acquired pneumonia CAP appears more likely to occur within 30 days of starting PPis-and especially within 48 hours. Rebound acid hypersecretion occurs when PPls are stopped abruptly after several months-especially in H. Drug interactions with PPls: PPis interact with few drugs and are generally well tolerated. Transient relaxations occur at increased frequency with gastric distension and in the upright position.
Hiatal hernia is risk factor for factor for GERD. LES pressure is increased by motilin, acetylcholine, and possibly gastrin. Therefore, drugs that increase these mediators tend to decrease reflux. LES pressure is decreased by progesterone pregnancy increases GE reflux , chocolate, smoking, and some medications, especially those with anticholinergic properties. This cough is commonly worse at night when the patient is supine. Most other GI-related chest pains are due to motility disorders. These pains are not necessarily associated with pyrosis heartburn or dysphagia.
Extraesophageal manifestations of GERD: A recent study showed that treatment of asymptomatic GERD in patients with severe asthma did not improve asthma control.
More in the Pulmonary section, Book 2. If immunocompetent, treat. If immunocompromised, treat based on biopsy. If a patient has dysphagia and symptoms of obstruction, a barium swallow may precede endoscopy. Figure These indicate the need for what? And with what? Do not assume asthma is the culprit in patients who complain of nocturnal symptoms. VCD is spasm of the vocal cords with associated inspiratory stridor. Patients will tell you that they are wheezing at night and may not really know ifit is inspiratory or expiratory.
Pulmonary function testing may be necessary to help distinguish vocal cord dysfunction from asthma. VCD is not always due to GERO; it is more typically seen in young adults who engage in competitive sports and is thought to be a stress reaction. Diagnosis of GERO Ifthe patient has only the classic symptoms ofheartburn without alarm signals, the diagnostic workup starts with a therapeutic trial ofPPis-EGD is indicated only ifthis trial fails Figure If the patient has obstructive symptoms, you can do a barium swallow before endoscopy.
This is termed nonerosive reflux disease or NERD! You then analyze the diary logs and pH monitor results for correlation. Ifthe above is unsuccessful, try antisecretory drugs. Overall healing ofpatients with endoscopic evidence of esophagitis not necessarily GERO!
In patients with GERO symptoms who do not respond to PPis, check for other medications that may delay gastric emptying and thus promote reftux--especially calcium channel blockers, antihistamines, narcotics, tricyclics, and anticholinergics.
Consider antireftux surgery fundoplication, now mostly laparoscopic in patients with severe GERO because With Nissen fundoplication, the lower esophagus is wrapped in a sleeve of the stomach. Side effects of this surgery are bloating, dysphagia, and an inability to belch.
You must do a motility study prior to antireflux surgery-because the results may influence the performance of the fundoplication. Endoscopic antireflux procedures are not ready for routine use.
Metoclopramide due to too many side effects and sucralfate not very effective have little use in treatment ofGE reflux. Long-term use of H2 receptor blockers is typically ineffective.
The need for screening for Barrett's is a controversial topic because ofthe absence ofrandomized clinical trials that prove a decrease in mortality with screening. Incidence of adenocarcinoma in patients with Barrett esophagus is Image Barrett esophagus 30x the nonnal rate.
Risk of adenocarcinoma is 0. Neither antireflux medication nor surgery reverses the epithelial changes of Barrett esophagus--or eliminates the cancer risk. For any high-grade dysplasia, eradication therapy is now recommended over surveillance. Photodynamic therapy PDT is occasionally used as well. Esophagectomy is an alternative treatment for patients with high-grade dysplasia but has higher morbidity and should be done by centers that specialize in this type of surgery.
See more in previous discussion. It is associated with other cancers of the head or neck and is rarely associated with achalasia, lye stricture, or Plummer-Vinson syndrome see page Incidence of squamous cancer has a marked geographic variation, and its occurrence appears to be strongly associated with diet and environment. Diagnosis of esophageal cancer is accomplished with a number of tests. Dysphagia is the usual presenting symptom, so a barium swallow during the workup may suggest cancer.
Use CT scan and endoscopic ultrasound for staging. If small and localized, treat with surgical resection. Patients have foul-smelling breath and may regurgitate food eaten several days earlier. These patients are often elderly. Treatment is surgery.
See Figure The light green highlight shows the main pathway used in production ofgastric acid. G cells are in the pyloric antrum. More importantly, gastrin stimulates enterochromaffin-like ECL cells to produce histamine. The proton pump is the final common pathway for the action of these three receptors, which explains why PP! Gastrin is released into the circulation and is therefore an endocrinal stimulus for gastric acid release.
Gastrin is the dominant mediator ofpostprandial gastric acid production. Low pH decreases gastrin by stimulating the D-cells to produce somatostatin and the duodenum to produce secretin. Stomach Physiology Gastrin-releasing peptide is released onto G cells by parasympathetic stimulation of the vagus nerve a neurocrine effect.
Therefore, parietal cells are affected by endocrine, neurocrine, and paracrine stimuli. In patients with achlorhydria as in autoimmune gastritis or pernicious anemia, the serum gastrin level skyrockets because of the loss of this inhibitory effect. Both gastric acid and pepsin made from pepsinogen in the presence of acid not only digest food but also attack the mucosa!
Things to know about the mechanical actions of mixing and grinding: It includes epigastric fullness, belching, bloating, gnawing pain, and heartburn. It generally does not apply to severe pain. EGO is usually normal. Dyspepsia is generally classified by symptoms: GERO-like, ulcer-like improves on anti-ulcer therapy , and dysmotility-type improves on promotility drugs, such as metoclopramide.
There can also be overlaps in the types. So, how do we handle dyspepsia? Do the following: Classification by Histology A neutrophil infiltrate is seen in acute gastritis, while a lymphocyte and plasma cell infiltrate occurs with chronic gastritis. Histologic classification reflects the findings throughout the possible life of the disease: Biopsy of gastropathy shows atrophy of gastric glands with fibrosis but no inflammatory infiltrate.
Classification by Etiology Type A: Autoimmune, Atrophic, pem1c1ous Anemia, Achlorhydria. It affects the proximal stomach-timdus and body only.