Gastroenterology
PANRE Review
Brock Phillips, PA-C
OBJECTIVES
Review relevant GI A&P and topics covered
on PANRE Blueprint - buzzwords & key
points are noted in red
Score 100% on the GI section!
Clinical pearls to enhance your skill & comfort
with GI complaints
DISCLOSURES
None - I’m a practicing PA-C in the trenches,
fresh off my own PANRE recert in 2016! If I
did it, you can too!!!
GI IS JUST PLUMBING -
IT’S NOT BRAIN SURGERY!!!
ESOPHAGUS
Esophagitis
Motility disorders
Strictures
Neoplasms
Mallory-Weiss tear
Varices
Esophagitis
Infectious vs. non-
infectious
Infectious: Candida,
HSV (shallow ulcers),
CMV (deep)
Non-infectious:
GERD, Rads/chemo,
pill-induced (NSAIDs,
bisphosphonates,
Tetra/Doxycycline)
Esophagitis
Inflammation of the esophagus
S/SX: Odyno-/dysphagia (pain/difficulty w/
swallowing), chest/substernal pain
Workup: EGD, BX
TX: Stop offending agents, address
comorbidities, Fluconazole, Magic
Mouthwash, PPI
Motility Disorders
Arise from disorders of smooth muscle or
intrinsic nervous system
Dysphagia (to liquids, solids or both) is MC
presenting complaint
Examples: Achalasia, Esophageal spasm,
Scleroderma, CVA
Achalasia
Loss of ganglion cells in Auerbach’s plexus -
increased tone, impaired relaxation of LES,
absent peristalsis
S/SX: Dysphagia to solids/liquids, regurg of
non-digested/non-acidic material
DX: “Bird’s beak” on barium swallow, EGD,
esophageal manometry
TX: Dilatation, botox, esophagomyotomy
Achalasia
Strictures
Narrowing of the esophagus
Can be anatomic or result from GERD,
esophagitis, NG tube injury
Examples: Schatzki’s ring, Zenker’s
diverticulum, Esophageal web
Schatzki’s Ring
Circumferential lower
esophageal ring, often
assoc. w/ hiatal hernia &
GERD
S/SX: Intermittent
dysphagia to solids, GERD
DX: EGD, barium swallow
TX: Dilatation
Zenker’s Diverticulum
Outpouching of
proximal esophageal
mucosa
S/SX: Dysphagia,
regurgitation, halitosis,
globus, aspiration risk
DX: EGD, barium
swallow
TX: Soft diet, surgery
Esophageal Web
Thin, found in mid-upper esophagus
Plummer-Vinson syndrome - webs assoc. w/
severe Fe deficiency. Combo of this plus
koilonychia (spoon-shaped nails), glossitis,
chelosis - also Fe def SX
TX: Fe supplement, dilatation
Mnemonic: ”The plumber Vincent DIGS a
hole for the iron pipe” (dysphagia, iron def,
glossitis, squamous cell ca risk ↑ )
Plummer-Vinson Syndrome
Esophageal Cancer
Predominantly M>F (3:1), older (50-70)
Squamous cell ca - prox 2/3 esophagus,
ETOH/smoking = risk factors
Adenocarcinoma - distal 1/3 esophagus,
Barrett’s esophagus = risk factor
Esophageal Cancer
S/SX: Progressive
dysphagia, wt loss
DX: EGD w/ BX,
endoscopic U/S,
CT
TX: Chemo/rads,
surgical resection
Barrett’s Esophagus
Complication of GERD (10% of cases) w/
chronic inflammation leading to metaplasia
40x increased risk of esophageal cancer!!!
Mallory-Weiss Tear
Superficial mucosal tear at gastroesophageal
junction due to vomiting/retching
S/SX: Painless hematemesis
TX: Usually self-limiting, EGD w/ thermal
coagulation or epi
…not to be confused with…
Boerhaave’s Syndrome
Esophageal rupture due to forceful vomiting,
instrumentation (s/p EGD)
S/SX: Tearing pain & hematemesis, crepitus,
“Hamman’s crunch” on auscultation
DX: Mediastinal widening on CXR, CT
TX: Surgical consult STAT, ABX, antiemetics,
Esophageal Varices
Dilated submucosal veins in lower esophagus
due to cirrhosis, portal HTN
30% w/ varices bleed - 30% of those will die,
bleeding is often recurrent
S/SX: UGIB w/ brisk BR hematemesis, +/-
melena, +/- hypoTN & instability
TX: IVF, blood, octreotide, EGD
banding/sclerotherapy
STOMACH
GERD
Gastritis
Peptic Ulcer Disease
Neoplasms
Pyloric Stenosis
Gastroesophageal Reflux Dz
Decreased LES tone leading to reflux of
gastric contents into esophagus
S/SX: Heartburn, regurgitation, chest pain,
chronic cough, laryngitis
DX: Clinical
TX: Antacid/H2/PPI, weight/diet/lifestyle,
surgical fundoplication
Can lead to reflux esophagitis, strictures,
Barrett’s esophagus
Gastritis
Inflammation of
stomach lining
(ETOH, NSAIDs, H.
pylori, stress/illness)
S/SX: Dyspepsia,
upper abd pain, N/V
DX: EGD w/ BX, H.
pylori testing
TX: Like GERD
Peptic Ulcer Disease
Ulceration resulting from
imbalance between
aggressive/defensive
factors of gastroduodenal
mucosa
Caused by H. pylori,
NSAIDs, secretory issues
Duodenal 5x more
common than gastric
Peptic Ulcer Disease
S/SX: “Gnawing, burning” epigastric pain,
episodic, +/- UGIB, gastric outlet obstruction
Worsened w/ eating (GU), begins hours after
meal/alleviated by eating (DU)
DX: H. pylori serology/breath/stool, EGD BX
TX: “Triple therapy” – PPI, Amox,
Clarithromycin (“Prevpac”). Quadruple w/
Pepto an option also.
Gastric Cancer
MC Adenocarcinoma - M>W, older (40+).
Lymphoma rare, but non-Hodgkins mets MC
to GI
S/SX: Dyspepsia, wt loss, anemia, GIB,
Virchow node (supraclavicular), Sister Mary
Joseph’s nodule (periumbilical)
DX/TX: EGD w/ BX, CT, resection w/ or w/o
rads/chemo
Gastric Cancer
Pyloric Stenosis
Narrowing of opening (pylorus) between
stomach and duodenum
M>F 4:1, infants 3 wks. - 5 mos.
S/SX: Forceful non-bilious vomiting soon
after feeding, fussy/hungry, palpable olive-
shaped mass (pylorus) in upper abdomen,
hypochloremic/hypokalemic met acidosis
DX/TX: Clinical HX/exam, abd U/S, surgery
Pyloric Stenosis
GALLBLADDER
Acute / chronic cholecystitis
Cholangitis
Cholelithiasis
Gallbladder Disease
S/SX: Episodes of colicky, RUQ pain often
after a fatty meal. Five F’s. +/- Fever, N/V.
+ Murphy’s sign - fingers under R costal
margin, pt. inspires deeply, winces & stops
due to pain/GB inflammation.
+ Boas’ sign - pain may occasionally radiate
to tip of R scapula
Gallbladder Disease
DX: WBC, LFTs,
U/S (gallstones w/
acoustic shadowing,
pericholecystic fluid,
GB wall thickening >
3 mm), HIDA scan
TX:
Cholecystectomy,
ERCP
Spectrum of Gallbladder Dz
Gallbladder Buzzwords
Five F’s - “Female, Forty, Fat, Fair & Fertile”
Charcot’s Triad - RUQ pain, jaundice & fever
Reynolds’ Pentad - Charcot’s + AMS/hypoTN
Above = likely septic w/ cholangitis, high mortality
Courvoisier’s Sign - pt. w. painless jaundice
and palpable, NT enlarged GB = cancer at
head of pancreas
LIVER
Acute / chronic hepatitis
Cirrhosis
Neoplasms
Hepatitis
Inflammation of liver (infectious vs.
non-infectous)
S/SX: Jaundice (>70%), vague abd
discomfort (most likely RUQ), nausea,
pruritis, tea-colored urine & clay-colored
stool, flulike prodrome
Hepatitis
DX/TX: LFTs, hepatitis
panel. Supportive care,
interferon/nucleoside
analogues. Vaccinate
against other forms.
Concurrent HIV TX
PRN. Liver txplt.
Viral Hepatitidies (sp???)
Hep A (acute, fecal/oral)
Hep B (acute & chronic, sex/blood)
Hep C (acute & chronic, IVDU MC, blood/sex)
Hep D (only as co-infection w/ Hep B)
Hep E (acute, fecal/oral, 20% mortality preg F)
Vaccines available for Hep B/C
Needlestick risks = Hep B 6-30% 😯
Hep C 1.8%, HIV 0.3%
Hepatitis
ETOH-related
AST:ALT > 2:1
Toxic (Tylenol OD)
Rumack-Matthew
nomogram for
acute OD, give N-
acetylcystine (NAC)
if indicated - not
useful for chronic
ingestion, however
Autoimmune
Alphabet soup!
Hep B rundown, as simple as I can make it?!
Acute Hep B = HBsAg+, IgM anti-HBc+
Prior HBV infxn, now immune = HBsAg-, anti-
HBs+, anti-HBc+
Received HBV vaccine = HBsAg-, anti-HBs+,
anti-HBc-
Hep B Chronic carrier = HBsAg+, IgM anti-
HBc-, anti-HBc(total)+
Hepatitis Serology
Cirrhosis
Injury to liver causing necrosis & fibrosis
(ETOH, hepatitis, drugs, biliary issues, etc.)
S/SX: Jaundice, portal HTN, ascites, hep
encephalopathy, asterixis/flap, easy bleeding
DX & TX: LFTs along w/ CBC, renal function,
PT/INR, CT/MRI
Liver Cancer
Hepatocellular carcinoma caused by
cirrhosis, Hep B/C/D, aflaxtoxin, etc.
S/SX: 1/3 aSX initially, abd pain, S/SX of
chronic liver dz
DX: LFTs, Elevated alpha-fetoprotein (70%),
paraneoplastic syndromes, imaging showing
mass, BX
TX: Resection/txplt, chemo/rads, poor
prognosis
PANCREAS
Acute / chronic pancreatitis
Neoplasms
Pancreatitis
Inflammation & autodigestion of the pancreas
Acute MC causes: ETOH, gallstones
Chronic MC cause: ETOH
S/SX: Mid-epigastric/upper abd pain w/
radiation to back, worse lying flat, N/V
Cullen’s sign: periumbical ecchymosis
Grey-Turner’s sign: flank ecchymosis
Pancreatitis
Pancreatitis
DX: Elevated lipase (>300, but may be
normal in chronic) & amylase (non-specific),
U/S to r/o gallstones if new DX, CT in some
cases to eval for pseudocyst/necrotic
elements
TX: Bowel rest / NPO, IVF, pain control
Ranson’s Criteria at time of admit (‘Don’t
mess with the “GA LAW!”’) and 48h later to
estimate mortality
Pancreatic Cancer
Adenocarcinoma of pancreatic duct
M>F 2:1, typically older (70-80) but
exceptions (ex: Steve Jobs)
S/SX: Abd pain, jaundice, wt. loss, N/V
DX: Labs, CT, endoscopic U/S w/ FNA BX
TX: Surgery/Whipple procedure in select few,
chemo/rads.
Overall prognosis = bad. 1 yr 20%, 5 yr 7%
SMALL INTESTINE / COLON
Appendicitis
Celiac disease
Lactose Intolerance
Constipation
Diverticular disease
Intussusception
Inflammatory Bowel Disease
Irritable Bowel Syndrome
SMALL INTESTINE / COLON
Ischemic Bowel Disease
Neoplasms
Obstruction
Polyps
Toxic Megacolon
Appendicitis
Inflammation of the appendix caused by
obstruction of appendiceal lumen by fecalith
MC surgical emergency - typically 10-30 y/o
S/SX: Periumbilical pain migrating to RLQ
(McBurney’s point), anorexia, N/V, +/- fever
Psoas, Rovsing & Obturator signs as well
DX: WBC, CT/US, lap appy alone to DX/TX if
your surgeon is convinced by HX/exam, ABX
PRN perf’ed/sick
Appendicitis PE Made Easy
A = McBurney’s Point
B = Rovsing’s
C = Psoas
D = Obturator
Celiac Disease
Gluten-sensitive enteropathy
characterized by malabsorption
S/SX: Diarrhea, steatorrhea,
bloating, wt. loss, rash
DX/TX: Antibody testing, small
bowel BX, response to gluten-
free diet - no wheat/barley/rye.
Rice/corn/oats OK.
Lactose Intolerance
Insufficient lactase enzyme leading to
fermentation of lactose by intestinal bacteria
w/ subsequent gas/acid production
MC among Asian Americans (>85%)
S/SX: Abd. bloating, gas, cramping, diarrhea
DX: Clinical, lactose breath H+ test to confirm
TX: Lactose-free diet, lactase enzyme
supplements (Lactaid, Dairy-Ease)
Constipation
If you need a formal definition: < 3 BMs a
week, hard/painful to pass. < 1 = severe
S/SX: Surely you don’t need my help w/ this?
DX: MRI, colonic content BX (just kidding…)
TX: Fiber > 20-35g/day, fluids, exercise, stool
softeners, laxatives (osmotic, stimulant, etc.)
Biggest thing? Watch for red flags. Wt loss,
severe abd pain, obstructive SX, blood.
Diverticular Disease
Diverticulosis = saclike protrusions of colonic
mucosa herniated thru defect in muscle layer
S/SX: Most aSX, painless rectal bleeding in some
Diverticulitis = inflammation/perf of diverticuli
S/SX: LLQ pain, +/- fever, +/- bleeding
DX: WBC, CT, empiric TX if HX of same/mild
TX: ABX (Cipro/Flagyl vs. Zosyn), bowel rest, pain
control, surgery in complicated/recurrent cases
Intussusception
Occurs when portion of intestine telescopes
inside another portion - causes pain, possible
obstruction/bowel ischemia. MC 3 mos.-3 yrs.
S/SX: Colicky/episodic pain increasing in
duration/freq, pulling knees to chest, N/V,
“currant jelly stools,” sausage-shaped lump
DX/TX: IVF, U/S showing “bulls-eye,”
air/barium enema (often DX/curative),
surgery PRN otherwise
Intussusception
Inflammatory Bowel Disease
Crohn’s = Transmural inflammation (all
layers) of bowel, spares rectum in some
S/SX: Abd pain, +/- bloody diarrhea w/
skip lesions, cobblestoning, abscess/fistula,
perianal dz., aphthous ulcers
Ulcerative Colitis = inflammation of mucosa
alone, always starts in rectum
S/SX: Abd pain, bloody diarrhea w/ continuous
lesions, “lead pipe” colon, 30x ↑ colon ca risk
Crohn’s Disease
DX: CT, endoscopy/colonoscopy w/ BX
TX: Sulfasalazine or mesalamine, PO steroid
taper, immunosuppressants, surgery
Ulcerative Colitis
DX: Sigmoidoscopy w/ BX
TX: Sulfasalazine or mesalamine, PO steroid
taper, immunosuppressants, surgery
Irritable Bowel Syndrome
Functional disorder w/o clear/known etiology
or underlying damage. Often comorbid w/
psych issues, chronic fatigue.
S/SX: Abd. pain, bloating & alteration in
bowel patterns (diarrhea, constipation, both)
DX: R/O alt causes (infection, celiac dz., IBD,
malignancy), Manning/Rome criteria
TX: Diet, fiber, mood, laxatives,
antidiarrheals, antispasmodics
Ischemic Bowel Disease
Inflammation, injury & potential death of
portion of lg. intestine 2/2 inadeq. blood
supply - vascular dz., clot, low-flow state
MC affects superior mesenteric a., older pt.
w/ HX of CAD/A. fib and/or septic/hypoTN
S/SX: Acute = “pain out of proportion to
exam”, melanotic/bloody stool
Chronic = pain shortly after eating, wt. loss
Ischemic Bowel Disease
DX: Mesenteric angiogram, CT
TX: IVF, bowel rest, +/- ABX, surgery PRN
Colorectal Cancer
Neoplasm arising from lumen of lg. bowel -
2nd MC cancer death in US, peak 70 y/o
Risk factors: FHX, IBD, age, diet, hereditary
polyposis.
S/SX: Initially vague w/ malaise, anorexia, wt
loss. Progressing to pain, rectal bleeding
obstruction.
DX: Colonscopy w/ BX, “apple core” lesion on
barium enema, anemia, CEA (tumor marker)
Colorectal Cancer
Bowel Obstruction
Partial or complete blockage of small or large
bowel due to adhesions, hernia, fecal
impaction, volvulus or neoplasm/mass
S/SX: Abd. pain, distention, absence of
flatus/stool. Hyperactive BS progressing to
hypoactive/absent.
D/DX: “Air-fluid levels,” “string of pearls” on
XR for SBO, “coffee bean”/”bent innertube”
for volvulus - CT definitive
TX: Bowel rest, NG tube, surgery PRN
SBO XR
Volvulus XR
RECTUM
Anal fissure
Abscess / fistula
Fecal impaction
Hemorrhoids
Neoplasms
Anal Fissure
Tear in epithelial lining of anal canal
S/SX: Tearing pain w/ defecation, BRB on TP
DX: Clinical - typically posterior (90%) or
anterior midline. If not or deeper, purulent,
abnl. appearance - consider alt. etiology?
TX: Sitz baths, stool softener, NTG ointment
Abscesses & Fistulas
Purulent fluid collection and/or abnormal
communication between anal canal and
perianal skin. Can be linked to IBD.
S/SX: Fluctuant/draining swelling or
open/communicating fistula around anus.
Tenderness/mass on DRE.
DX: Clinical exam. CT w/ contrast to
determine extent/depth or communication.
TX: I&D abscess in appropriate setting,
surgery, manage underlying condition (IBD)
Fecal Impaction
The name says it all – need I say more?
Consider red flags such as neoplasm if not
c/w stool bolus alone.
S/SX: Constipation or scant watery diarrhea
around impacted stool.
DX: DRE, imaging PRN
TX: DRE, enemas, DisImpactor to the
rescue!
Hemorrhoids
Varices of hemorrhoidal plexus either above
(internal) or below (external) dentate line
S/SX: BRB on TP, pain & pruritus (external),
thrombosis (external)
DX: Clinical, anoscopy
TX: Sitz baths, fluids & fiber, stool softener,
topical hydrocortisone/witch hazel,
suppositories. I&D clot. Surg/banding PRN.
MISCELLANEOUS
Hernias
Infectious & Noninfectious Diarrhea
Vitamin & Nutritional Deficiences
Phenylketonuria
Hernias
Exit of an organ through wall of cavity in
which it normally resides
Various types - hiatal, umbilical, ventral,
femoral, inguinal, incisional
Associations: Hiatal (GERD or newborns),
umbilical (congenital/infants), femoral
(elderly F’s), inguinal (lifting/strain)
Hernias
Indirect inguinal hernia (MC) - through
internal inguinal ring into inguinal canal
Direct inguinal hernia - through external
inguinal ring / Hesselbach’s triangle
DX: Clinical - CT PRN to eval for obstruction,
incarceration, strangulation
TX: Manual reduction, surgery PRN
Hernias
Infectious Diarrhea
Bacillus cereus = reheated/fried rice
Campylobacter = undercooked/raw poultry
C. botulinum = home canning, honey < 1 y/o
C. difficile = ABX (3 C’s: Clinda, Cipro, Ceph)
E. coli = fecal-oral, ”traveler’s diarrhea”
Giardia = camping, streams/creeks
Infectious Diarrhea
Listeria = unpasterurized milk/chz, deli meats
Salmonella = Eggs, poultry, meat
Shigella = Bloody/mucoid diarrhea, dysentery
Staph aureus = Potato salad, mayo, QUICK!!!
Vibrio = shellfish, “rice water stools,” cholera
Vitamin A
At risk: Elderly, ETOH’ics
Night blindness, dry skin, poor wound healing
Thiamine (B1)
At risk: ETOH’ics, poor
Wernicke’s encephalopathy, Korsakoff syndrome,
Beriberi (wet & dry)
Vitamin & Nutritional
Deficiencies
Vitamin & Nutritional
Deficiencies
Niacin (B3)
At risk: ETOH’ics, poor
Pellagra/3 D’s (diarrhea, dermatitis & dementia)
Cobalmin (B12)
At risk: Elderly, vegans, atrophic
Vitamin C
At risk: ETOH’ics, elderly
Scurvy (bleeding gums, petechiae, poor healing)
Vitamin & Nutritional
Deficiencies
Vitamin D
At risk: Elderly, low sunlight, infants
Rickets, osteomalacia
Vitamin K
Bleeding, elevated PT
Phenylketonuria
Hereditary/recessive familial disease w/
deficiency of phenylalanine hydroxylase,
which is an enzyme responsible for
processing amino acid/building blocks of
protein in diet
Screened for at birth - can cause MR, musty
odor to urine, vomiting, convulsions, irritability
TX: Low phenylalanine diet, tyrosine supp.
REMEMBER – IT’S NOT
EXACTLY BRAIN SURGERY…
Practice Questions…
A 72 y/o F presents w/ difficulty
swallowing solids - daughter reports
halitosis along w/ “coughing up bits of
food sometimes.” She also has HX of
recent admit for asp. PNA. What underlying
condition is likely causing her dysphagia?
Achalasia
CVA w/ resultant neuromuscular dysfunction
ETOH’ism
Zenker’s diverticulum
Schatzki’s ring
Which of the following meds is typically
not included as a part of either triple or
quadruple therapy for PUD?
Amoxicillin
Lansoprazole
Carafate
Bismuth subsalicylate
Clarithromycin
A 24 y/o F presents w/ c/o R flank pain,
anorexia, N/V and fever. UPT neg, U/A
w/ leuks, many epis but no nitrites/blood and
neg gram stain. WBC 19. She endorses pain
when you hyperextend R leg at hip. What is
most likely cause?
Pyelonephritis
Acute cholecystitis
Infected kidney stone
Retrocecal appendicitis
Gastroenteritis
While staffing a local UC, you have
3 patients who come in simultaneously
w/ N/V/D after attending a church potluck
earlier that afternoon. All are afeb, nontoxic
w/ benign abds and NBNB N/V/D. What is the
most likely organism causing their SX?
C. difficile
Campylobacter
Salmonella
Giardia
Staph aureus
What acute abdominal pathology can
present with abd distention, hypoactive
bowel sounds, NBNB N/V and “air-fluid
levels” on screening acute abd XR?
Volvulus
Perforated ulcer
Strangulated hernia
Small bowel obstruction
Thrombosed hemorrhoid