GI Consult Elective

I'll summarize some of the things I read for this elective below. 

Otherwise, I spent my days doing new consults and following up on my old consults. I learned a whole bunch and became clearer in my head that I'm not really drawn toward the procedural side of medicine. GI specialists know a lot of medicine but they are also technically adept at using endoscopes and all the tools that you can put on those scopes these days.

"Long-Term Colorectal-Cancer Incidence and Mortality after Lower Endoscopy" by Reiko Nishihara et all, NEJM 9/19/13

Colonoscopy and sigmoidoscopy are associated with a reduced incidence in left sided distal colon cancer. Right sided or proximal colon cancer is not reduced as much by colonoscopy, a fact that we learned last year. The polyps and other precancerous lesions are much more difficult to see in the right colon due to a different genetic mutation pathway. Cancers that pop up between colonoscopies are likely to have the "serrated pathway" mutations.

"American College of Gastroenterology Guideline: Management of Acute Pancreatitis" by Scott Tenner et all, 7/30/13

- Mild Acute Pancreatitis is self-limiting, does not have organ failure and/or pancreatic necrosis. Patients start eating again within 48hrs.

- Moderately Severe Acute Pancreatitis has local complications (fluid/necrosis) and/or transient organ failure (<48hrs).

- Severe Acute Pancreatitis has two phases:

1. early (first week) has SIRS and/or organ failure.
2. late (after the first week) characterized by local complications (peripancreatic fluid/necrosis/pseudocysts)

Diagnosis

1. Two of three criteria

     i) abdominal pain (epigastric or LUQ, constant, radiates to back, chest, or flanks)

     ii) serum amylase (rises in hours, falls in days) and/or lipase (more specific, stays elevated longer)greater than 3X the upper limit of normal

     iii) characteristic findings from abdominal imaging

2. CT and MRI should be reserved for patients who fail to improve clinically within the first 48-72hrs after hospital admission.

Etiology

1. Ultrasound on everybody to rule out gallstones.

2. History of EtOH (need 5 years of heavy drinking? If no, check serum triglycerides.

3. In patients older than 40yo, tumor should be considered.

Initial Assessment and Risk Stratification

1. Assess hemodynamic status.

2. Assess risk (age, obesity, mental status, comorbidities, SIRS, Labs, imaging)

3. If signs of organ failure, admit to ICU

Initial Management

1. Aggressive hydration (250-500mL/hr) is most beneficial during the first 12-24hrs. LR might have some advantages because prevents the hyperchloremic non-anion gap metabolic acidosis that is possible with large volumes of normal saline.

ERCP

do it within 24hrs of admission if cholangitis is sure.

don't do it if there is no evidence of obstruction

MRCP if no jaundice or cholangitis

use stents and NSAID suppositories after ERCP

Antibiotics

Give for extrapancreatic infection.

No role for prophylactic antibiotics

Carbapenems, punolones, and metronidazole penetrate pancreatic necrosis.

Nutrition

Start oral feeding asap when nausea and vomiting resove

Enteral nutrition better than parenteral if PO route not available.

Surgery

cholecystectomy before discharge unless necrotizing in whic case wait until inflammation subsides.

Persistence of Nondysplastic Barrett's Esophagus Identifies Patients at Lower Risk for Esophageal Adenocarcinoma: Results from a Large Multicenter Cohort by Srinivas Gaddam et all

Cyclic Vomiting Syndrome and Abdominal Migraine in Adults and Children by Randolph W. Evans and Chad Whyte

CVS is 5 separate attacks, episodic, stereotypical, vomiting, symptom free between attacks, not attributable to another disorder.

Epidemiology

2% of children

headache/migraine history

slight male predominance

Clinical Features

Four phases to each episode:

1. well phase without symptoms
2. prodrome with pallor, sweating, and nausea
3. intense vomiting
4. recovery phase

Pathophysiology

similar to migraines, periaquaductal grey matter, autonomic dysfunction.

"brain-gut" disorder mediated by the neuroendocrine system as evidenced by ACTH, ADH, cortisol, and other endocrine substances that rise in serum. CRF is stimulated by stress in the hypothalamus and it leads to delayed gastric emptying due to inhibiting the dorsal motor nucleus of the vagus nerve. TCAs inhibit the promoter activity of the CRF gene, and thus efficacious in treating CVS.

Differential Diagnosis

acute illness causes of nausea and vomiting.

Treatment

Supportive measures (hydration, electrolytes, quiet, dark, ondansetron, benzodiazepines, diphenhydramine.

Sumatriptin can be taken upon onset of episode.

Abortive agents include NSAIDS (ketorolac) and opioids.

Treatment with amitriptyline, venlafaxine

Prognosis

CVS resolves in many children by teenage years. 86% of adults are cured with TCAs.

abdominal migraines 

Epidemiology

slight femal predominance

5-15 years old

Clinical Features

Recurrent , episodic attacks of abdominal pain with associated nausea, vomiting, and or lethargy lasting as long as migraines.

Periumbilical pain.

Often premonition.

Pathophysiology

unknown

Differential Diagnosis

other causes of abdominal pain

Treatment

treated with prochlorperazine and eletriptan

avoid triggers, dietary management

IV valproate

Pizotifen, flunarizine

Propanolol, cyproheptadine.

I also read a whole bunch of textbook chapters from MD Consult, and learned a lot about diarrhea. I am starting to realize that information technology has changed medicine more quickly than the training can keep up with. As a medical student, I am able to become an expert on tiny pieces of medicine relatively quickly in a way that would not have been possible 10 years ago. It makes me think that the fragmentation of care is not really necessary. Why can't a family doctor refer a complicated patient to herself and spend the 3 or 4 hours that are required to access the detailed information about the complex management necessary. That same 3-4 hours will be spent by a slew of specialists who will use the very same resources (or likely have memorized them) to come up with the same answer. It seems to me that family doctors should have yearly exams, rotating through all of the traditional specialties each year, open book, to ensure that they are on top of their game, because they must recognize and diagnose diseases of every organ system. Better yet, patients should start out at specialists (knee pain, go to an orthopedic specialist) and then get referred to family doctors for management of complex, multiorgan/biopsychosocial challenges. Pay scales should be revered accordingly because specialists will actually need much less training than generalists. Training for specialties can be substantially shortened by skipping all the generalized stuff at the beginning. Technical wizardry would be mastered much more quickly just out of high school so why not get those same folks before they "waste their time" learning how to talk about feelings with their patients.

Primer of Palliative Care, 5th edition, by Timothy E. Quill et all

Read this book during my Palliative Care elective

1. Introduction

"The goal of palliative care is to prevent and relieve suffering, and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies". 

Hospice can be added on top of palliative care if the end of life is near, and focuses exclusively on caring, not curing.

2. Pain Management

Define what is causing the pain as precisely as possible.

Identify other limitations such as

• Renal insufficiency: (use methadone or fentanyl). Avoid morphine and codeine.
• Hepatic insufficiency: requires more caution with fentanyl, hydromorphone, oxycodone, and methadone. Avoid morphine.
• Cost: methadone is the most efficient.
• 
  

Add a prn that is about 10% of daily dose for breakthrough pain.

Opioid Caveats:

1. Respiratory depression is almost always preceded by sedation.
2. Constipation should be anticipated and treated prophylactically.
3. Nausea normally resolves after a few days.
4. Sedation is common in the beginning just like nausea.
5. Myoclonus means time to try another opioid or add a benzo.
6. Delirium must be analyzed carefully as the cause is usually multifactorial.
7. Urinary retention
8. Addiction
9. Pseudoaddiction is iatrogenic syndrome that mimics addiction behaviors due to inadequately treated pain.
10. Physical dependence is a physiologic withdrawal syndrome.
11. Tolerance is a state of adaptation.

3. Dyspnea

Treated most effectively with opioids. Second line is anxiolytics such as benzodiazepines. Corticosteroids can also be used to reduce airway inflammation and edema.

Respiratory secretions can be treated with atropine eye drops, scopalamine patch, glycopyrrolate IV or SC.

4. GI symptoms

The most important thing I learned from this chapter is that feeding tubes do not reduce aspiration events. That seems to go against what most doctors assume.

Also learned that IV fluids rarely reverse the circulatory shutdown at the end stages of illness and can potentially cause fluid overload, particularly as renal function worsens.

The anti-nausea drugs used in palliative care are quite effective.

Haloperidol for nausea caused by metabolites (liver failure, renal failure, tumor products)

Dexamethasone for raised ICP.

Meclizine for vestibular disease (H1 blocker, acts at CTZ?)

Octreotide especially if co-exists with bowel obstruction.

4D. Bowel obstruction causes pain, nausea, and vomiting. In palliative care we go straight for the symptoms.

Pain treated with Glycopyrrolate is antimuscarinic, Hyoscyamine is another antimuscarinic. Celiac plexus block is last resort.

4E Constipation.

Increase fluid and fiber (psyllium, methylcellulose) intake.

Stool softeners = detergent laxitives = docusate sodium

Stimulants = Senna and Bisacodyl

Osmotic agents (8) = glycerin, sorbitol, lactulose, polyethylene glycol, milk of magnesia, magnesium citrate, sodium phosphate.

Enemas (5) = warm water, saline, mineral oil, milk and molasses, soap suds.

Prune juice, 

Metoclopramide

Methylnaltrexone is mu opioid receptor antagonist

Lubiprostone is chloride channel activator

5. Delirium, Depression and Anxiety, Fatigue, and Spirituality

Delirium = Encephalopathy = an acquired syndrome of disordered consciousness and cognition that develops over a short period of time and fluctuates during the course of the day. Can have different levels of psychomotor activity. Polypharmacy in up to 60% of hospitalized patients. Second most common cause is metabolite build up. Third is infection. Then a bunch of other less common causes. 

First treat the underlying cause if possible. Treat symptoms with haldol or other antipsychotic. Benzos can cause paradoxical agitation. Ritalin can be used for hypoactive delirium.

It seems important to differentiate 

loss of hope, 

loss of meaning, 

loss of value, 

loss of relationship. 

For each of these feelings, acknowledge, explore, legitimize, empathize.

How to take a spiritual history: SPIRIT

- Spiritual belief system

- Personal spirituality

- Integration in a spiritual community

- Ritualized practices and restrictions

- Implications for medical care

- Terminal events planning

Dignity Therapy is "a therapeutic intervention aimed at alleviating suffering and depression and helping patients find and reshape meaning and dignity".

• Most important accomplishments and what do you feel most proud of?
• Words or instruction for your family to help them prepare for the future?
• Any particular things you still need to say to your loved ones?

6. Goal setting, prognosticating, and Self-Care

Six steps to establishing patient centered goals

1. Prepare and plan by identifying stakeholders and have pre-meeting huddle to align agenda with those concerned.
2. Find out what the patient and family know and how much they want to know.
3. Review what the medical teams know and fire a warning shot. Discuss prognosis and benefits and burdens of treatment options. Pause frequently to check for understanding.
4. Respond empathetically after you have delivered the news. Listen more than talk. 
5. Identify and resolve conflicts. Use "I wish" statements.
6. Elicit values and preferences in order to establish patient-centered goals. Be prepared to make a recommendation. Summarize the meeting, establish plan, follow-up.

7. Last-Resort Options 

Proportionate Palliative Sedation

"If rapid sedation to unconsciousness is felt to be the best approach because of the patient's unique clinical circumstances, then it is critical to have experts in palliative care and ethics involved before initiation to ensure all other approaches have been fully considered and the circumstances warrant the intervention.

Ventilator Withdrawl

Requests for "hastened death"

8. Care during the last hours of life

Pediatrics flash lessons learned

"Does This Child Have Acute Otitis Media?" R Rothman et all

Otitis media costs about $5billion a year. 

Happens most in kids 6-18months old.

Breast feeding is protective.

S. pneumoniae, H. influenza (often co-existing conjunctivitis), C. moraxella.

Look at position, color, landmarks, degree of translucency, and mobility.

Ear pain is the only useful symptom, but only has a likelihood ratio of only 3.0. 

Signs are more useful:

Distinctly impaired mobility has LR of 31.

Cloudy opaque eardrums also have LR of 34.

Bulging has LR of 51.

In conclusion, "a tympanic membrane that is cloudy, bulging, or distinctly immobile is highly suggestive of acute otitis media".

I also learned about magic mouth wash for the mouth lesions that cocksackie virus causes (BMX = lidocaine+malox,+diphenhydramine)

The difference between lactose intolerance and milk protein allergy.

Difference between allergy shiner and Dennie-Morgan Folds.

Amelogenesis Imperfecta vs. Enamel Hypoplasia

HEEADSSS survey for adolescents.

How ring worm can cause kerions.

The 5S's of comforting babies (Suck, Swing, Swaddle, Shhh, Side/stomach position).

Treat ring worm with clotrimazole unless under hair where you need griseofulvin.

I loved this brief 2-week window into pediatrics. I seem to get along with kids pretty well and can put their parents at ease by clearly explaining everything I'm doing and the reason I'm doing it (or asking for it).

The most frustrating thing about pediatrics for me was the lack of interest and pride in gynecologic care of their female patients and overall sexual health of both males and females. The reality is that many kids are having sex in their teens and it has a profound effect on their physical and mental health. I want to practice in a specialty that allows me to directly address sexual health in a proactive rather than reactive way.

Surgery Rotation Complete

On the last day of surgery (a teaching day), we had a lecture about the culture of surgery and the skills required to accept feedback and criticism from those around you. 

It really struck a cord with me as my last three weeks of surgery were marred by my inability to respond appropriately on the second day when I had not completed the reading assigned to me. Besides the random facts of anatomy reviewed, the modest progress made on toward understanding more completely disease process and therapeutics, the largest and most important lesson I learned from surgery is that I must practice constant mindfulness in order to both give and accept evaluations in a constructive way.

This idea of a community where confrontation is acceptable and expected is quite possible, as I witnessed at Haverford. I have been working to make it more of a reality here in medical school through my work with the nascent honor board, but so far have not made much progress.

At the end of this morning's lecture, the presenter hit a brick wall in attempting to convince residents to be part of a culture change because they are afraid of retribution from their superiors. Ironically, any culture change in surgery will have to come from the top down. In the current culture, there is no way that a junior resident can call out a superior for making sexist jokes or practicing poor medicine and still expect to get a letter of recommendation upon which her future career depends.

The only part of surgery left to do is take the "shelf exam", a test which I am woefully unprepared for, mainly because it has so much medicine in it that I will experience much more through the rest of my rotations. But I had to have something first, so might as well get surgery out of the way.

Okay, back to doing practice questions...

Anton Chekhov stories

I started reading this sometime early in the spring when it was still cold outside. I didn't finish them until I was on the flight back from my Utah backpacking trip yesterday. There were some nights before step 1 where I would only read a paragraph or two before passing out each night.

The Death of a Clerk

Small Fry

The Huntsman

The Malefactor

Panikhida

Anyuta

Easter Night

Vanka

Sleepy

A Boring Story

Gusev

Peasant Women

The Fidget

In Exile

Ward No. 6

The Black Monk

Rothschild's Fiddle

The Student

Anna on the Neck

The House with the Mezzanine

The Man in a Case

Gooseberries

A Medical Case

The Darling

On Official Business

The Lady with the Little Dog

At Christmastime

In the Ravine

The Bishop

The Fiance

So there really were a fair number of stories. Many of them gave me homesick feelings toward Ukraine. Chekhov portrays the sharp edges of poverty and second/third world survival simultaneously commenting on the bleakness wealth without goodness.

I am enchanted at the beginning of each story by how Chekhov sets the scene, from the sounds to the smells, I slip into the scene and can embrace the normalcy of the thoughts and dialog that takes place in each locale.

How Doctors Think by Jerome Groopman

fascinating analysis of cognitive error

underlined how important it is to think about how you think

reminded me of taking some time to learn how I learn

so that I can then be a bit more efficient as I prepare for step 1

it's a bit of a weight on my shoulders

so far I haven't been able to work at quite the volume that I would like

but then again, we still have classes, outpatient office days, and some other random school work to do.

Soon enough, I'll be able to let go completely and study to my hearts content, 9+ hours each day

I guess medical school self selects for people who find this enjoyable...

Animal, Vegetable, Miracle by Barbara Kingsolver

I read this as part of my humanities seminar entitled "Evil Bananas". 

While I went into the class thinking that I may already be part of the choir,  I actually learned a fair bit about food systems here in rochester. This book however tended to grind on my nerves, if only for the cliched tone and ditzy voice. Kingsolver did pursue a cool idea though. She decided to try to eat a mostly local diet with her family for a year, and then write about it. This required first that she move from AZ to VA. Then she started a huge garden and even got some turkeys and chickens. 

The idea of eating local seems to provide a pretty tremendous environmental impact reduction, and not only because of transport. When people get food from people they know, there is direct feedback about how it is grown and how the land is used. People are then willing to pay more for a product that does not destroy the land. A close correlate to eating locally is eating seasonally. This requires re-learning many things about food storage, so that peppers from July and August can be safely eaten in February. This is exciting because my experiences of eating this way in Ukraine have left such a powerful impression on my food choices, and I will continue to make small changes toward eating and living in this way.

Even with all of the advantages of eating local, I have been unable to convince my roommate to give up bananas. This despite the monoculture approach, low wage labor, and huge transport costs. I guess in many respects we have become so accustomed to having food from all over the world regardless of the local season.

Beyond having geographic awareness food production, the level of processing is now clearly linked to the health status of everybody. The trend is simple: less processed = more healthy. Interestingly, choosing less processed foods often leads to more local foods.

Finally there was one small section that pretty persuasively argued against the use of GMO rice with vitamin A to solve the world blindness problems. The argument is that these areas need rice that can be re-planted, and not become slaves to a copyrighted genome that could be taken away in the future. It also argues that real solutions would improve the root cause of these nutritional deficiencies, which is poverty. Therefore local agricultural solutions, including the elimination of free trade agreements which saturate markets with super cheap staples, would allow local farmers to become part of the solution. Obviously this problem has many possible solutions, but I have begun to become convinced that simply dumping more free food, supplemented or not, is merely a patch, a lid perhaps, on the coming revolution.