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米国にて内科修行中。何ができるか模索している過程を記録していく

Gastroenterology (memo from NEJM knowledge plus and MKSAP)

・how long patient with upper GI bleed and high-risk lesion on upper endoscopy need to be observed in hospital after successful procedure

72 hours (high-risk peptic ulcer: active bleeding, visible vessel)

 

・management of opiod-induced constipation refractory to standard laxative

methylnaltrexone

 

・management of recurrent obscure GI bleeding with negative upper endoscopy and colonoscopy

repeat upper endoscopy +/- colonoscopy

(capsule endoscopy and single-balloon endoscopy are reserved for patient with negative for repeated endoscopy and colonoscopy)

 

・management of obscure GI bleeding requiring 1 unit transfusion every 3 days, negative upper endoscopy and colonoscopy 2 times, negative capsule endoscopy

nuclear scintigraphy 

(nuclear scintigraphy requiring bleeding rate 0.1-0.5 ml/min to detect, angiography reguiring bleeding rate > 1 ml/min)

 

・screening for hereditary nonpolyposis colorectal cancer

colonoscopy initiated by age of 20 to 25 or 10 years prior to the earlest age colorectal cancer diagnosis in the family

 

・colon cancer screening for ulcerative colitis

every 1-2 years, beginning 8-10 years after diagnosis

 

・colon cancer screening for patient with positive family hitory (father at 54 yo)

every 5 years, initiating at age of 40 

(first degree with CRC < 60 yo: initiate at 40 yo or 10 years younger than age at diagnosis)

 

・postpolypectomy surveillance (1.5cm villous adenoma, low-grade dysplasia and 6mm tubular adenoma, low-grade dysplasia)

colonoscopy in 3 years

(high risk adenoma: > 3 adenomas, > 1cm, villous morphology, high-grade dysplasia)

 

・management of patient with bright red blood per rectum with syncopal episode, BP 88/58, HR 123, Hb 7.3, nasogastric tube aspirate negative

upper endoscopy first, then colonoscopy if negative

(bright red blood per rectum associated with ongoing brisk bleeding from upper source, nasogastric tube placement miss up to 15% of active bleeding)

 

・follow up resolution of uncomplicated acute diverticulitis

colonoscopy to rule out other disorders that mimic diverticulitis, such as cancer or Crohn disease

 

・Tx for moderately to severely active Crohn disease

anti-TNF agent (infliximab)

 

・follow up patient with h/o familial adenomatous polyposis syndrome after total colectomy

periodic upper endoscopy to screen ampullary adenocarcinoma

 

・prevention of esophageal variceal rebleeding 

beta blocker and serial band ligation every 3-4 weeks (PPI no role in secondary prevention of esophageal variceal bleeding)

 

・management of type 1 gastric carcinoid tumor with size of 1cm after removal 

follow up endoscopy in 6 months (rarely metastasis occur, 5 years-survival 95%)

 

・management of traveler's diarrhea without alarm symptoms (fever, hematochezia)

supportive care

 

・management of patient with severe diarrhea after massive small-bowel resection for acute mesenteric ischemia

PPI

(surge of gastric acid in the postoperative period -> inactivate pancreatic lipase -> diarrhea)  

 

・two most common complication of Meckel's diverticulum

GI bleeding (acid secreted by heterotopic gastric mucosa) and small-bowel obstruction (intussusception)

 

・Tx for constipation-predominant irritabl bowel syndrome refractory to fiber and standard laxatives

lubiprostone

 

・imaging study for suspected insulinoma if contrast CT negative

endoscopic ultrasound

 

・diagnosis of patient with diarrhea, bloating, weight loss, vit B12 deficiency with elevated folate

small intestinal bacterial overgrowth

 

・management of immune-tolerant hepatitis B (positive HBsAg, HBeAg, high HBV-DNA,  normal ALT)

monitor ALT every 3-6 months

(as long as pt maintain normal ALT, low risk for progression of liver disease, once ALT elevated -> biopsy -> initiate Tx )

 

・management of patient who present with hematemesis, hemodynamically unstable even after 2L of IV normal saline and 2 units of transfusion

continue IV hydration and transfusion (upper endoscopy after hemodynamic stability achieved)

 

・indication for liver biopsy in hereditary hemochromatosis

> 40 yo, ferritin > 1000

 

・diagnosis of patient with passive movement of undigested stomach contents into the mouth without retching, then spit or reswallow

Rumination syndrome

 

・management of cirrhotic patient with large esophageal varices (>5mm)

non-selective beta blocker or endoscopic ligation 

 

・diagnostic study for acute acalculous cholecystitis

US has better sensitivity than CT

 

・management of eosinophilic esophagitis

PPI 6 weeks first to exclude GERD

(EE can occur secondary to GERD, no criteria to distinguish EE from GERD)

 

・first-line therapy of achalasia

laparoscopic myotomy

 

・unexplained iron deficiency anemia in patient with Down syndrome with negative result of upper endoscopy, colonoscopy and serum tissue transglutaminase IgA Ab

repeat upper endoscopy with small bowel biopsy

(celiac disease, sensitivity of serum tissue transglutaminase IgA Ab significantly varies among lab)

 

・if bowel preparation is poor for screening colonoscopy

repeat colonoscopy before planning long-term surveillance program