Gastrointestinal System

PANCE Review
Presenter
Kristin Hoffman, PA-C
ED & MCPHS Adjunct
 Gastrointestinal System Approach

• Acute vs Chronic, recurrent

• Abdominal Quadrant
• Stable vs. unstable vital signs
• Risk factors: age, gender, Past surgical Hx,
PMH, habits-ETOH, routine screening
• Infectious vs. inflammatory vs. ischemic
• Surgical vs non-surgical
• Non-gastrointestinal: Cardiac, urogenital,
renal, zebras
Classification of Gastrointestinal disease

• Impaired digestion/absorption
• Altered secretion
• Altered gut transit
• Immune dysregulation
• Impaired blood gut flow - ischemic
• Neoplastic degeneration
• Disorders w/o obvious organic abnormalities
• Genetic influences
 Gastrointestinal System/Nutrition
Esophageal disorders (9% PANCE)
• Esophagitis • Gastroesophageal reflux disease • Mallory-Weiss tear •Motility disorders • Strictures • Varices •dysphagia
Gastric disorders
• Gastritis • Peptic ulcer disease • Pyloric stenosis
Gastrointestinal bleeds
• UGIB (>BUN to Cr levels), dark/black oxidized •LGIB bright red stools•Rectal
Biliary disorders
• Acute/chronic cholecystitis • Cholangitis • Cholelithiasis
Hepatic disorders
• Acute/chronic hepatitis • Cirrhosis •portal hypertension
Pancreatic disorders
• Acute/chronic pancreatitis
Small intestine disorders
• Appendicitis • Celiac disease • Intussusception • Obstruction • Polyps
Colorectal disorders
• Abscess/fistula • Anal fissure • Constipation • Diverticulitis • Fecal impaction • Hemorrhoids •Inflammatory bowel disease •
Irritable bowel syndrome • Ischemic bowel disease • Obstruction • Polyps • Toxic megacolon –IBD complication• diarrhea
Food allergies and food sensitivities
• Gluten intolerance • Lactose intolerance • allergies
Metabolic disorders
• G6PD deficiency • Paget disease • Phenylketonuria • Rickets
Nutritional and vitamin disorders
• Hypervitaminosis/hypovitaminosis • Obesity •malabsorption
Neoplasms • Benign • Malignant
Other: • Hernias • Ingestion of toxic substances or foreign bodies
 ROS
Indigestion, regurgitation, heartburn, abdominal fullness, pain
after meals sudden vs delayed, burning, gnawing, colicky,
radiates to back/flank/shoulder, nausea, vomiting-cyclical, stress,
diarrhea, hematemesis, melena, hematochezia, mucus, pain out
of proportion, distension, bloat, guarding, steatorrhea, pale
stools, dark urine, ecchymosis, change appetite, Wt loss/gain,
fever, travel, medications, rectal pain, jaundice, scleral icterus,
pallor, dizziness, SOB, caput medusae, telangiectasia, chest pain,
intermittent, constant, rash/skin changes, pallor, syncope,
lightheadedness, dizziness, constipation, suicidal ideation,
factitious/ munchausen d/o, pre-post prandial symptoms,
 Physical Exam
• Fever – inflammation/neoplastic
• Hemodynamic stability – hypotension, tachycardia
• Orthostasis – blood loss, sepsis, dehydration, autonomic neuropathy
• Skin, eyes, joints – inflammatory, jaundice, rash, ecchymosis, kayser-Fleischer
rings, erythema nodosum
• Cardiopulmonary – may present as abd pain/N
• Auscultation -Bruits w/vascular dz, bowel sounds/borborygmi
• Percussion – shifting dullness, dull, tympanic
• Palpation – Quadrant localization, organomegaly, masses. Severe pain w/o
tenderness, quadrant, visceral vs peritonitis guarding/rebound , CVAT
• Pelvic exam
• Rectal exam – masses, hemoccult, retrocecal appendicitis,
hemrrhoids/fissure/abscess/ pilonidal cyct
Vital signs, orthostatic VS- dehydration from N/V/D
Urine/serum Hcg Work-up
CBC – leukocytosis, anemia, differential, Heme/Oncology
CMP- tansaminitis, e-lytes, uremia, BUN/cr ratio Amylase, lipase
Lactate -ischemic vs infectious
Blood cultures
U/A- culture – ketones, hematuria, infection, osm, urine Na,
Hepatitis panel – acute/chronic transaminitis
Beta-hydroxybutyrate – ketones/DKA, ABG – acid-base abnormalities
Stool studies-lactoferrin, c diff, culture, ova & parasites
Barium swallow study – dysphagia, spasms/dysmotility, schatzki rings,
EGD & colonoscopy – varicies, gastric/duodenal ulcers, colon lesions/polyps/CA. Contrast enema. Capsule endoscopy.
Laparoscopy - exploratory
Inflammatory markers – ESR, CRP
Ammonia
ERCP/MRCP- upper abd ductal obstruction, HIDA Scan
Abdominal CT +contrast -
Ultrasound -pregnancy, pediatric, upper abd, female pelvic, renal
EKG- injurious patterns, e-lyte abn
KUB/CXR-stool burden, FB, gas, dilated loops, air fluid levels
hemoccult stool test
PT/PTT, Type and Cross, Rh
Urine drug tox, APAP levels, Copper
Peritoneal fluid evaluation (ascites)
Histopathology
Various hormone levels, Tumor markers
 GERD – common
• HPI: Worse after meals, burning sensation,
substernal/epigastric, sour/metallic taste d/t
stomach acid. Triggered by eating before bed,
obesity, ETOH/tabacco/caffeine/chocolate are
modifiable risk factors.
• Tx PPI Omeprazole or H1 inhibitors,
dietary/behavioral changes. When is and EGD,
CXR, EKG, abd imaging recommended?
 Upper GI Alarm symptoms
RED Flags:
Elder age >45
Unintentional Wt loss
Heme+ stools/blood in stool (ddx hemrrhoids vs CA)
Anemia
Long standing GERD
Dysphagia
Cardiac risks
 Case 1
35 yo female otherwise healthy, presents to the clinic with a Hx
of abdominal discomfort, sometimes accompanied with gas
and diarrhea over a period of several weeks- months. She
denies blood in the stools, no change in weight, fever, or
recent travel. Abdominal exam is unremarkable with non-
tender abdomen, and negative stool guaiac. Which is the most
likely?
(a) IBD
(b) IBS
(c) Lactose intolerance
(d) Celiac dz
 Case 2
52 yo female PMH emphysema, obesity, b/l knee OA, presents with
moderate 7/10 epigastric pain, she denies pain that radiates to the
back/shoulder, and states symptoms improve after a “glass of milk
and bread” but return hours later. Physical exam reveals localized
mild tenderness to the epigastrium, and rales bilaterally, otherwise
unremarkable. Which is the next recommendedstep for evaluation?
(a) EGD
(b) Serologic testing for H. pylori
(c) Serum gastrin level
(d) Barium xray
(e) Abdominal CT
 Case 3
21 yo male, presented to the ED, brought by friends, after a night
of celebrating his birthday, with episodes of vomiting, which has
now become bright red blood in the ED. He appears drowsy, and
intoxicated. BP 125/78, P 90, RR 13, Temp 98.2. Physical exam is
unremarkable. Which is the next step?

(a) Barrium xray

(b) Abdominal CT
(c) EGD
(d) Consult general surgery
(e) Observation
 Case 4
46 yo female, presents to the ED c/o nausea, and sudden 8/10
epigastric pain after binge drinking that radiates to the left
sided back, worse with laying supine. BP 129/82, P 108, RR 18,
temp 100.8. Physical exam reveals epigastric, LUQ pain, and a
visualized healed incision over the RUQ. IV Fluids have been
started. What is the most likely Dx?
(a) Cholecystectomy
(b) Acute pancreatitis
(c) Chronic pancreatitis
(d) Diverticulitis
(e) Small bowl obstruction
 Case 5
68 yo male presented to the ER c/o diffuse 7/10 abdominal pain with episodes
of nausea and vomiting, last bowel movement was 3 days ago. BP 140/86, P 90,
RR 14, O2 Sat 98%, Temp 98.7. PMH HTN, afib, appendectomy, hernia repair,
diverticulitis. Last colonoscopy 1 yr ago, unremarkable. On physical exam, the
patient appears uncomfortable, irregular heartbeat, lungs CTA, abdomen
distended, diffuse tenderness. WBC 10, Which is the most likely finding?

(a) Dilated bowel loops w/air-fluid level, distal collapsed bowel

(b) Apple core lesion
(C) Gallbladder wall 5 mm and pericholecystic fluid 
(d) Colonic wall thickening and pericolic fat stranding
(e) Mesenteric fatty stranding, mesenteric lymph nodes, periintestinal fluid 
 Case 6
54 yo male presents to the ER c/o upper abdominal pain, intermittent nausea,
swaets, and increased belching for the past 2 days unrelieved by motrin.
-PMH nicotine dependence, HTN, HLD.
-PE Heart RRR, lungs CTA, abdomen is soft, mildly protuberant, mild TTP
epigatric area.
-CBC, CMP, lipase unremarkable.
What is the next best step?
(a) Reassure the patient, discharge w/ Rx Omeprazole, F/U w/ GI
(b) EGD
(c) Abdominal CT w/ IV contrast
(d) Upper abdominal U/S
(e) EKG
 Case 7
72 yo NH resident is brought to the ED c/o right-sided severe abdominal pain x
2hrs and worsening. No significant symptoms until today.
-BP 115/75 HR 105, RR 19, Temp 101.4 – borderline septic
-PE TTP along ascending colon.
Barium enema xray reveals no pneumoperitoneum. Some bowel wall thickening
and traces of air in the wall. While xray is being read, he passes stool with dark
clots not bloody diarrhea. Which of the following is the most likely diagnosis?

(a) Appendicitis
(b) Inflammatory bowl disease
(c) Intusussception
(d) Bowel wall perforation
(e) Ischemic colitis
 Case 8
28 yo tired appearing pale female presents to the clinic w/4 weeks of
bloody diarrhea with passage of mucus, episodes accompanied by
severe pain, and passage of mucus. Diffuse abd pain, most significant
in RLQ, normoactive bowel sounds. Labs reveal anemia. Temp 100.5.
Colonoscopy reveals lesions along the ascending and transverse colon
with no lesions in the rectum, what is the most likely Dx?

(a) Crohns dz
(b) Ulcerative colitis
(c) Gluten-sensitive eneropathy
(d) Appendicitis
(e) Ischemic colitis
 Case 9
25 yo female presents to her PCP with reports of abdominal pain
ongoing over the course of several months with episodes of both
diarrhea and constipation, she reports her symptoms are more
prominent throughout the day, and relieved by a bowel movement.
She has eliminated gluten and dairy from her diet and reports her
symptoms persist. She denies malaise, fever, wt loss, travel. Stool
cultures are normal. What is the most likely dx?
(a) IBD
(b) Infectious diarrhea
(c) Celiac disease
(d) IBS
(e) Malabsorption
C
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 Case 10
56 yo male, w/Hx ETOH abuse presents to ED vomiting
bright red blood x 3 episodes, and epigastric pain. BP
104/58 HR110, RR19, Temp 97.4. What is the next step?

(a) Packed RBCs

(b) Abdominal imaging
(c) NS IV Bolus
(d) EGD
(e) Platelet transfusion
 Case 11
35 yo caucasian male with presented to the ED c/o malaise,
bloody diarrhea x2weeks, with maroon color, 6/10 abdominal
discomfort “all over”, episodes of tenesmus, 10lbs wt loss in 6
mo, he reports taking pepto-bismol w/no improvement. BP
126/78, P 80, R 15, temp 100.5. Stool cultures are negative.
Which of the following is the gold standard for this diagnosis?
(a) Colonoscopy with Biopsy
(b) Abdominal CT
(c) Labs
(d) Hemoccult stool test
(e) Response to GI-cocktail
 Extraintestinal manifestations w/IBD

• Erythema nodosum – like red bruises/nodes

MC on shins
• Pyoderma gangrenosum—ulceration of skin
• iritis/scleritis—inflammation of the sclera
• Inflammatory arthritis
• Primary sclerosing cholangitis
 Case 12
57 yo male presented to the ER with severe abd pain gradually
worsening over the past week, and mild SOB, with low grade
temp. He denies N/V/D, trauma. Labs reveal Low serum albumin
with lower extremity edema, protuberant abdomen w/shifting
dullness w/percussion and spider angiomata on PE.
What is the most likely plan?
(a) Obtain CXR and administer Rocephin and doxycycline
(b) Consult surgery
(c) Consult IR, administer Spironalactone, octreotide, eventual
abx/third generation cephalosporin
(d) Place NG tube
 Case 13
68 yo male works as a butcher, PMH: nicotine dependence, HLD,
HTN. He presented to the ED with abdominal discomfort, and
episodes of constipation and pencil stools, he reports
unintentional 20 pound weight loss in the past 2.5 months. Labs
reveal a low H&H, and hemoccult stool test is positive. He is non-
compliant w/routine surveillance. What is the most common dx?
(a) Carcinoid tumor
(b) Adenocarcinoma
(c) Lymphoma
(d) Sarcoma
(e) Hyperplastic polyp
 Case 14
73 yo female presented to the ED with abd pain 3x days c/o low
grade fever, exam reveals soft flat abdominal tenderness LLQ, no
rebound or guarding. She denies bloody or black stool, urinary
symptoms, nausea/vomiting, distension, back pain. Labs reveal
WBC 20, lactate 2.5, U/A clear, hemoccult stool test is negative.
What is the most likely diagnosis?
(a) Urolithiasis
(b) Appendicitis
(c) Pneumoperitoneum
(d) Diverticulitis
(e) pancreatitis