GASTROENTEROLOGY

							                       PRINCE GEORGE’S HOSPITAL CENTER
                    INTERNAL MEDICINE RESIDENCY PROGRAM

                         SECTION 10: GASTROENTEROLOGY


This section has been reviewed and approved by the Chief, Division of Gastroenterology as
well as the Program Director, Internal Medicine Residency Program at Prince George’s
Hospital Center.

________________________                           ______________________________
Chief, Division Of Gastroenterology                Program Director, Residency Program



I. Overview

      Gastroenterology encompasses the evaluation and treatment of patients with disorders
      of the gastrointestinal tract, pancreas, biliary tract, and liver. It includes disorders of
      organs within the abdominal cavity and requires knowledge of the manifestations of
      gastrointestinal disorders in other organ systems.

      The general internist should have a wide range of competency in gastroenterology and
      should be able to provide primary and, in some cases, secondary preventive care,
      evaluate a broad array of gastrointestinal symptoms, and manage many gastrointestinal
      disorders. The general internist is not expected to perform most technical procedures
      with the important exception of flexible sigmoidoscopy. However, he/she must be
      familiar with the indications, contraindications, interpretations, and complications of
      these procedures.

      The goal of this rotation is to provide the internal medicine resident with the ability to
      evaluate and manage an array of gastrointestinal and hepatologic symptoms and
      disorders. Residents may be given an opportunity to assist faculty during select
      endoscopic procedures. This rotation will help residents evaluate and develop a
      diagnostic and therapeutic approach to patients with general gastroenterology and
      hepatology disorders. The residents will learn screening guidelines for colon cancer
      and other gastroenterologic disorders.

      During the rotation the residents do inpatient consults with the staff attending, observe
      and participate in certain procedures including endoscopies, PEG placements etc, give
      at least one subspecialty noon conference as well as see patients in the outpatient
      setting once a week with a GI attending. Resident responsibilities are detailed in Section
      I of the Resident Handbook. The resident is supervised for all patients by a staff
      Gastroenterologist for all patients.


II.   Principle Teaching Methods

      It consists of frequent encounters with the attending physician regarding patient care.
      The resident will discuss all patients with the attending physician and interpret clinical
      data to formulate a differential. The attending will assign reading topics on a regular
    basis and review the material with the residents. This will include accepted national
    guidelines as well as upcoming treatment modalities in the management of various
    gastroenterologic diseases. The faculty will also critique the residents consult notes,
    examination and management plan. Rounds will include short 15-30 minute discussions
    on current topics driven by patient encounters and initiated by resident and completed by
    the attending physician on most days. Latest information dealing with the topic as
    provided by literature search and pertinent articles should be discussed. Residents
    should become familiar with the indications and screening for Colon Cancer and other
    common GI diseases by the end of the rotation. The residents are also exposed to a
    variety of cases of viral and chemical hepatitis as well as to procedures like ERCP and
    MRCP.

    Residents are required to review a minimum number of test results with the attending on
    service to meet the requirements of the rotation. These requirements are listed in the
    logsheet at the end of this section. Residents must print a double-sided copy of the
    logsheet and complete the requirements and turn in the logsheet to the program
    coordinator at the end of the month to get credit for the rotation. All topics listed in the
    logsheet must be discussed in detail during the rotation.

    The residents must also observe and assist where applicable the attending physician
    during procedures like PEG placement, EGD, Colonoscopy. During the rotation the
    resident must present a topic during GI Conference. The topic must be discussed with
    the attending physician and chief residents beforehand to ensure the following spectrum
    of diseases are covered in the entire academic year:
         GI bleed- upper and lower
         Pancreatitis
         Colitis- ischemic, inflammatory, radiation
         Motility disorders- esophagus, intestinal, gastroparesis
         Hepatits- viral, alcoholic, drug induced, ischemic
         Malignancies- pancreatic, colon, MALT, hepatoma, metastatic disease,
         Diarrhea- secretory, osmotic, infectiousEnd stage liver disease
         HIV associated upper and lower GI infections
         Gall bladder and biliary duct related- gallstones, cholecystitis and cholangitis

III. Strengths and Limitations

    The gastroenterology faculty consists of a volunteer faculty that has a strong
    commitment to patient care and resident education. The patient and disease exposure is
    broad. The residents have close interaction with the faculty with daily rounds and
    procedures (endoscopies, PEG placement etc.). The faculty is also easily accessable to
    the residents for patient care related issues during the day via phone and comes in to
    the hospital for any GI emergencies. The residents also gain exposure to outpatient
    management of GI cases by attending the weekly GI clinic at Gleridge Medical Center.
    The experience gained is typical of a community hospital.


IV. Goals and Objectives for Gastroenterology Rotation

    Legend of Learning Activities
    Learning Venues
    1. Direct Patient Care/Consultation
       2.   Attending Rounds
       3.   Gastroenterology Clinic
       4.   Self study
       5.   Gastroenterology conference
       6.   Core Lecture Series

       Evaluation Methods
       A. Attending Evaluations
       B. Direct Observation
       C. 360O evaluation
       D. Intraining examination

Competency: Patient Care                              Learning Venues   Evaluation methods
Demonstrate the ability to use history, physical      ALL               A, B, D
exam, laboratory, and ancillary tests to assess
the status of a patient with acute gastrointestinal
hemorrhage
Interview patients more skillfully, gathers           1, 2, 3           A, B
accurate and essential information with
emphasis on gastrointestinal illness
Examine patients more skillfully with competent       1, 2, 3           A, B
and complete observation of normal and
abnormal signs
Define and prioritize patient’s medical problems      1, 2, 3, 4        A, B, D
Generate and prioritize differential diagnoses        1, 2, 3, 4        A, B, D
with appropriate testing and therapeusis
Develop rational, evidence-based management           1, 2, 3, 4        A, B, D
strategies
Demonstrate ability to generate differential          ALL               A, B, D
diagnosis, diagnostic strategy, and define the
appropriate therapeutic plan and ongoing
modifications in a patient with GI diseases
Competency: Medical Knowledge
Articulate the pathophysiology, evaluation and        ALL               A, B, D
management of patients with GI diseases and
their complications
Expand clinically applicable knowledge base of        ALL               A, D
the basic and clinical sciences underlying the
care of medical service patients, both out and
inpatients.
Access and critically evaluate current medical        ALL               A, B, D
information and scientific evidence relevant to
patient care
Competency: Interpersonal and
Communication Skills
Interact in an effective way with physicians and      1, 2, 3           A, B, C
nurses participating in the care of patients
requiring gastroenterology consultation and care
Communicate effectively with patients and             1, 2, 3           A, B, C
families, with particular emphasis on explanation
of complex and multisystem illness and the
testing required to confirm diagnositic
possibilities
Present patient information concisely and            1, 2, 3          A, B, C
clearly, verbally and in writing. Adhere to
confidentiality
Teach colleagues effectively                         ALL              A, B, C
Show understanding of differing patient              1, 2, 3          A, B
preferences in diagnostic evaluation and
management of gastrointestinal disorders
Competency: Professionalism
Treat team members, primary care givers, and         1, 2, 3          A ,B, C
patients with respect
Actively participate in consultations and rounds     1,2              A,B
Attend and participate in all scheduled                               Singn in on
conferences                                                           attendance sheet
Demonstrate respect, compassion, integrity and       1, 2, 3          A, B, C
altruism towards patients, families, colleagues,
and all members of the health care team
Demonstrate sensitivity to confidentiality,          1, 2, 3          A, B, C
gender, age, cultural differences and disabilities
Identify deficiencies in peer performance            ALL              C
Competency: Practice Based Learning
Identify limitations of medical knowledge in         ALL              A, D
evaluation and management of patients with
gastrointestinal disorders and use the medical
literature to address these gaps
Competency: Systems-Based Practice
Understand and utilize the multidisciplinary         ALL              A, B, C
resources necessary to care optimally for
hospitalized and out patients and the limitations
of various practice environments.
Collaborate with other members of the health         1, 2, 3          A, B, C
care team to assure comprehensive patient care
Use evidence-based, cost-conscious strategies        ALL              A, D
in the care of hospitalized and outpatients


   V. Educational Content

       A. Acute GI conditions
          1) Understand the differential diagnosis, appropriate tests and management of:
              Acute abdomen
              Acute appendicitis
              Ascites
              GI bleed
              Bowel obstruction, ischemia
          2) Develop procedural skills in and interpret results of:
              Paracentesis
              Placement of nasogastric tube
              Fecal leukocytes
              Test for occult blood
B. Esophagus
   1) Understand the differential diagnosis, appropriate tests and management of:
       Barrett’s esophagus
       Squamous and adeno carcinoma,
       Esophagitis – acid and other (Monilia, CMV, etc.)
       Motility Disorders
       Varices
   2) Interpret results of:
       24-hour esophageal pH monitoring
       Bernstein test
       Contrast studies (including upper gastrointestinal series, small-bowel follow
          through, barium enema)
       Esophageal manometry

C. Stomach and Duodenum
   1) Understand the differential diagnosis, appropriate tests and management of:
       Ulcer disease
       Hiatal hernia illness
       Foreign body and Bezoar
       Gastritis – drugs, H. pylori and stress
       Motility disorders and mitotic disease
       Malignancy
   2) Interpret results of:
       Assays for Helicobacter pylori
       Biopsy of the gastrointestinal mucosa
       Upper endoscopy
       Scans of gastric emptying
       Gastric acid analysis, serum gastrin level, secretin stimulation test

D. Intestine
   1) Understand the pathophysiology of:
        Motility
        Digestion and absorption
   2) Understand the differential diagnosis, appropriate tests and management of:
        Infection,
        Malabsorption
        Short bowel syndrome, bacterial overgrowth
        HIV illness
        Obstruction and pseudo-obstruction
        Tumors
        Inflammatory Bowel disease
   3) Interpret results of:
        Colonoscopy
        Computed tomography, magnetic, resonance imaging, ultrasound of the
           abdomen
        Culture of stool for ova, parasites
        D-xylose absorption test and other small bowel absorption tests
        Endoscopic retrograde cholangiopancreatography
        Examination for stool for ova, parasites
          Fecal electrolytes
          Fecal osmolality
          Mesenteric arteriography
          Qualitative and quantitative stool fat
          Serum B12 and Schilling tests
          Tumor markers

E. Colon and Rectum
   1) Understand the differential diagnosis, appropriate tests and management of:
       Inflammatory Bowel disease
       Angiodysplasia
       Irritable Bowel Syndrome
       Diverticulosis, diverticulitis,
       Colitis – (viral, bacterial, collagenous, lymphocytic, etc.)
       Cancer
       Polyposis syndromes
       Hemorrhoids
       Anusitis
       Appendiceal disease
   2) Interpret results of:
       Lactose and hydrogen breath tests
       Colonoscopy
       Flexible sigmoidoscopy
       Laxative screen

F. Liver
   1) Understand the differential diagnosis, appropriate tests and management of:
       Fatty liver, NASH, cirrhosis
       Cholestasis
       Viral hepatitis, use of Interferon
       Portal hypertension – TIPS, banding, surgery
       Ascites
       Hepatic encephalopathy
       Hepato-renal syndrome
       Autoimmune hepatitis
       Drug induced and alcoholic disease
       Hemochromatosis
       Polycystic disease
       Abscesses (bacterial an Amebic)
       Liver carcinoma, metastatic disease to the liver
       Transplantation
   2) Interpret results of:
       Computed tomography, magnetic resonance imaging, ultrasound of the
          abdomen
       Blood tests for autoimmune, cholestatic, genetic liver diseases
       Viral hepatitis serology, Liver function tests
       Discriminant function
       Liver biopsy
       Percutaneous transhepatic cholangiography, ERCP, MRCP
   G. Biliary Tract Disease
      1) Understand the differential diagnosis, appropriate tests and management of:
           Acute cholecystitis
           Biliary obstruction
           Cholangitis iincluding Sclerosing cholangitis
           Primary biliary cirrhosis
           Cholelithiasis
      2) Interpret results of:
           Gall bladder radionuclide scan
           Percutaneous transhepatic cholangiography, ERCP, MRCP
           Autoimmune serologies
           Liver function tests

   H. Pancreas
      1) Understand the differential diagnosis, appropriate tests, and management of:
          Acute pancreatitis and its complications
          Chronic pancreatitis and its complications
          Pancreatic cancer
      2) Understand and interpret results of:
          Amylase and lipase
          CT scans of the abdomen
          ERCP, MRCP
      3) Understand indications for ERCP, stents and radiation therapy

   I.   Miscellaneous
        1) Peritonitis
        2) HIV disease and its affect on various GI organs
        3) Approach to patient with:
            Nausea and vomiting
            Abdominal pain
            Diarrhea
            Constipation
            GI bleeding, appropriate tests and management including bleeding scan
        4) Endoscopy relating to GI illness and effects of therapeutic procedures
           (polypectomy, sphincterotomy, etc.)
        5) Pathology and its relation to GI disease – biopsy interpretation, stool for O & P,
           duodenal drainage, liver biopsy, cytology, etc.
        6) Gastrointestinal manifestation of diabetes, chronic renal disease
        7) Gastrointestinal care in the surgical patients

VI. Recommended Readings

   All senior residents are encouraged to read the MKSAP for Gastrenterology during their
   one-month rotation. Questions will help develop analytical thinking. Residents should
   also consult Harrison’s Principles of Internal Medicine. Residents are also encouraged to
   read from MDConsult and Up To Date on a case by case basis. Other recommended
   readings are as follows:
1) Bounds BC and Friedman LS. Lower gastroeintestinal bleeding. Gastroenterol Clin
   North Am. 2003 Dec;32(4):1107-25.

2) Swaroop VS. Colonoscopy as a screening test for colorectal cancer in average-risk
   individuals. Mayo Clin Proc. 2002; 77: 951-956

3) Tremaine WJ. Practice guidelines for inflammatory bowel disease: an instrument for
   assessment. Mayo Clin Proc. 1999; 74: 495-501

4) Podolsky DK. Inflammatory bowel disease. NEJM, Aug 8, 2002; 347(6): 417-429

5) Farrell RJ and Kelly CP. Celiac sprue. N Engl J Med. 2002 Jan 17;346(3):180-8

6) Tamboli PC. Current medical therapy for chronic inflammatory bowel diseases. Surg
   Clin N Am 87 (2007), 697-725

7) Szarka LA. Diagnosing gastroesophageal reflux disease. Mayo Clin Proc. 2001; 76:
   97-101

8) Arora AS. Medical therapy for gastroesophageal reflux disease. Mayo Clin Proc.
   2001; 76: 102-106

9) Huang CS and Lichtenstein DR. Nonvariceal upper gastrointestinal bleeding.
   Gastroenterol Clin North Am. 2003 Dec;32(4):1053-78

10) Mertz HR. Irritable bowel syndrome. N Engl J Med. 2003 Nov 27;349(22):2136-46.

11) Shiotani A and Graham DY. Pathogenesis and therapy of gastric and duodenal ulcer
    disease. Med Clin North Am. 2002 Nov;86(6):1447-66

12) Suerbaum S and Michetti P. Helicobacter pylori infection. N Engl J Med. 2002 Oct
    10;347(15):1175-86

13) Ragni et al. Survival of Human Immunodeficiency virus-Infected liver transplant
    recipients. JID 2003: 188 (15 Nov) 1412-1420

14) Torriani et al. Peginterferon Alfa-2a plus Ribavirin for Chronic Hepatitis C virus
    infection in HIV-infected patients. NEJM 2004; 351: 438-450

15) Imperiale et al. Fecal DNA versus Fecal Occult Blood for Colorectal-Cancer
    screening in an Average-risk Population. NEJM 351; 26: 2704-2714

16) Bjelakovic et al. Antioxidant supplements for prevention of gastrointestinal cancers: a
    systematic review and meta-analysis. The Lancet vol 364: 1219-1228

17) Marik P and Zaloga G. Meta-analysis of parenteral nutrition versus enteral nutrition in
    patients with acute pancreatitis. BMJ vol 328: 1407-1410

18) Moayyedi et al. An update of the Cochrane Systematic review of Helicobacter Pylori
    eradication therapy in nonulcer dyspepsia: Resolving the discrepancy between
    systematic reviews. AM J Gastroenterology. Vol 98 No. 12, 2003: 2621-2626
19) Wong B et al. Helicobacter Pylori eradication to prevent gastric cancer in a high-risk
    region of China. JAMA Jan 14,2004. Vol 291, No 2: 187-194

20) Isenmann R et al. Prophylactic antibiotic treatment in patients with predicted severe
    acute pancreatitis: A placebo-controlled, double-blind trial. Gastroenterology 2004;
    126: 997-1004

21) Moayyedi et al. The efficacy of proton pump inhibitors in nonulcer dyspepsia: A
    systematic review and economic analysis. Gastroenterology 2004; 127: 1329-1337

22) Whitcomb D. Acute Pancreatitis. NEJM 354; 20, May 18,2006: 2142-2150

23) Mannon P et al. Anti-interleukin-12 antibody for active Crohn’s disease. NEJM 351;
    20, Nov 11, 2004: 2069-2079

24) Krawitt E. Autoimmune hepatitis. NEJM 354; 1, Jan 5, 2006: 54-66

25) Mukherjee S et al. Beta-Blockers to prevent Esophageal varices- An unfulfilled
    promise. NEJM 353; 21, Nov 2005: 2288-2290

26) Gines P et al. Management of cirrhosis and ascites. NEJM, Apr 15 2004; 350(16):
    1646-1654

27) Binder H. Causes of Chronic diarrhea. NEJM 355; 3, July 2006: 236-239

28) Schoenfeld P et al. Colonoscopic screening of average-risk women for colorectal
    neoplasia. NEJM 352; 20, May 2005: 2061-2068

29) Musher D and Musher B. Contagious acute gastrointestinal infections. NEJM 351;
    23, Dec 2004: 2417-2427

30) Navarro V, Senior J. Drug-related hepatotoxicity. NEJM 354; 7, Feb 2006: 731-739

31) Hoofnagle J. Hepatitis B – Preventable and now treatable. NEJM 354;10, March
    2006: 1074-1076

32) Liaw Y et al. Lamivudine for patients with chronic hepatitis B and advanced liver
    disease. NEJM 351; 15, Oct 2004: 1521-1531

33) Poland G, Jacobson R. Prevention of Hepatitis B with the Hepatitis B Vaccine. NEJM
    351; 27, Dec 2004: 2832-2838

34) Hampel H et al. Screening for the Lynch syndrome (Hereditary nonpolyposis
    colorectal cancer). NEJM 352; 18, May 2005: 1851-1860

35) Meyerhardt J, Mayer R. Systemic therapy for colorectal cancer. NEJM 352; 5, Feb
    2005: 476-487

36) Suk-Fong A. The maze of treatments for Hepatitis B. NEJM 352; 26, Jun 2005: 2743-
    2746
                        PRINCE GEORGE’S HOSPITAL CENTER
                        INTERNAL MEDICINE RESIDENCY PROGRAM

                             GASTROENTEROLOGY LOGSHEET

     RESIDENT NAME______________________________________________

     PGY LEVEL_______________          ROTATION MONTH_____________
                                                                     DIARRHEA &
                                          BILIARY
                        PANCREATITIS                    GI BLEED      MOTILITY
                                         DISEASES
                                                                     DISORDERS
        MR#
Assessment and Plan
   Discussed with
        resident
    Comment by
supervising attending
 (Resident diagnosis
 correct/not, missed
     findings etc)
   SIGNATURE of
    Supervising
 attending & DATE
        MR#
Assessment and Plan
   Discussed with
        resident
    Comment by
supervising attending
 (Resident diagnosis
 correct/not, missed
     findings etc)
   SIGNATURE of
    Supervising
 attending & DATE
        MR#
Assessment and Plan
   Discussed with
      resident
    Comment by
supervising attending
 (Resident diagnosis
 correct/not, missed
     findings etc)
   SIGNATURE of
    Supervising
 attending & DATE
      RESIDENT NAME:___________________________________________

                                        POLYP
                           HEPATITIS                 ABDOMEN CT   ASCITIC FLUID
         TEST                           BIOPSY
                            PROFILE                     SCAN      / IBD FINDINGS
                                        RESULT
         MR#

Resident’s diagnosis and
          plan
Comment by supervising
 attending (correct/not,
  missed findings etc)
    SIGNATURE of
Supervising attending &
         DATE
         MR#

Resident’s diagnosis and
          plan
Comment by supervising
 attending (correct/not,
  missed findings etc)
    SIGNATURE of
Supervising attending &
         DATE
         MR#

Resident’s diagnosis and
          plan
Comment by supervising
 attending (correct/not,
  missed findings etc)
    SIGNATURE of
Supervising attending &
         DATE
         MR#
Resident’s diagnosis and
          plan
Comment by supervising
 attending (correct/not,
  missed findings etc)
    SIGNATURE of
Supervising attending &
         DATE