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    Gastroenterology Hospital Handbook
    Gastroenterology Hospital Handbook
    Gastroenterology Hospital Handbook
    Ebook132 pages1 hour

    Gastroenterology Hospital Handbook

    By Mark Prince and Julianna Lindsey

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    About this ebook

    A practical guide to the evaluation and management of digestive disorders for use by gastroenterologists, hospitalists, fellows, advanced practice provicers, and medical students. Need to know information to help you start gastroenterology consults for inpatients.

    LanguageEnglish
    PublisherMark Prince
    Release dateSep 5, 2019
    ISBN9781393872597
    Gastroenterology Hospital Handbook

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    Book preview

    Gastroenterology Hospital Handbook - Mark Prince

    1.png

    Copyright 2018. All rights reserved. No part of the material may be reproduced or utilized in any form without written permission from the copyright owner.

    The content, statements, views, and opinions herein are the sole expression of the authors. Reference to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply endorsement or recommendation. Gastroenterology Hospital Handbook is an independent publication and has not been authorized, sponsored, or approved by owners of the trademarks or services referenced in this product.

    The authors have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or any outcomes related to the use of the contents of this book and take no responsibility for the use of the products or procedures described. Treatments and side effects described in this book may not be applicable to an individual patient. Drugs and medical devices discussed may have limited availability controlled by the Food and Drug Administration (FDA) for clinical use.

    When considering a diagnostic test or treatment for an individual patient, the healthcare provider or reader is soley responsible for determining the needed testing and treatment plan. The healthcare provider or reader is also solely responsible for reviewing FDA status, reading package insert, and reviewing prescribing information.

    Table of Contents

    Introduction 5

    1. GI History 6

    2. GI Physical Exam 8

    3. Labs and Imaging 11

    4. Endoscopy 13

    5. Abdominal Pain: Epigastric and Right Upper Quadrant 16

    6. Abdominal pain, LLQ and RLQ 21

    7. Upper GI bleed, Hematemesis and Melena 26

    8. Lower GI bleed, Hematochezia 30

    9. Jaundice and Increased Liver Enzymes 34

    10. Ascites and Cirrhosis 38

    11. Acute Liver Failure 43

    12. Pancreatitis and Increased Lipase 47

    13. Inflammatory Bowel Disease, Crohn’s and Ulcerative Colitis 52

    14. Dysphagia 57

    15. Nausea and Vomiting 60

    16. Diarrhea 64

    17. Constipation and Ileus 67

    18. New Mass or Abnormal Imaging 70

    19. Malnutrition and Enteral Tubes 74

    20. GI Surgeries 77

    Introduction

    Our handbook is designed to be a practical guide for the care of hospitalized patients with gastrointestinal complaints. We focus on the initial history, physical examination, and diagnostics.

    Inpatient care is increasingly a team function. Multiple providers typically see a gastroenterology patient: patients are evaluated in the emergency department, admitted to hospitalists or intensivists, and consulted upon by gastroenterology. Not all hospitals have GI resources at the ready, so this book is intended for use by specialists and generalists alike. We believe this resource will be valuable to physicians and advanced care providers.

    Optimal care requires focus at each evaluation step, communication between patient and providers, and efficient resource utilization. The wrong initial diagnosis and poor communication can slow patient recovery and prolong hospitalization, frequently increasing morbidity and mortality. Testing and therapies evolve, but the process of interview, examination, and plan development remain the same.

    Key history, physical exam, and objective data relevant to gastroenterology are outlined. A cognitive support framework is used to analyze acquired data to develop a differential diagnosis for common scenarios. Appropriate testing can confirm the working diagnosis and allow treatment to begin. We hope this handbook will be both a resource and refresher for physicians and advanced practice providers who evaluate GI patients.

    1. GI History

    Take-Aways:

    Take your time. Get the specifics of the presenting illness.

    Introduce yourself and sit down. Sitting down is a key action.

    Correlate symptoms to eating, drinking, and bowel movements.

    Location is the most valuable descriptor of abdominal pain.

    Ask GI specific review of systems questions.

    Obtaining an accurate history of presenting illness is the key to an efficient and effective evaluation. As Sir William Osler implied, patients will tell you what is wrong with them if you will listen. Understanding the narrative of each patient’s illness is critical. After introducing yourself, sit down. Sitting helps gain trust with the patient and family. Ask the patient, family, and/or caregivers to restate the presenting symptoms. Accurate information saves wasted resources, shortens hospital stay, and helps get your patients well sooner.

    Presenting details include the onset, duration, location, severity, quality, context, and associated symptoms. Location is usually the most helpful descriptor with abdominal pain. In addition, the relationship to food intake and bowel movements is important. Ask about the most recent oral intake in case an emergency procedure is necessary. Verbally read-back a symptom summary to the patient to increase the patient’s confidence in you and allow for corrections.

    All medications are important: prescription, over the counter, and supplements. Anticoagulant and antiplatelet use must be considered before any endoscopic or surgical procedures. Past medical and surgical histories are important to understand the context of current illness. Weight loss surgery is particularly important since it changes the digestive tract structure.

    Frequently, gastroenterology inpatients are older with comorbidities. Assess baseline functional status before scheduling any procedure. Behaviors like smoking, smokeless tobacco, EtOH, and illicit drugs are risk factors for many diseases. Ask about marijuana use in patients with nausea or vomiting. Don’t assume elderly or clean patients do not use illicit drugs. In certain cases, travel, work, and environmental exposure can be useful. Medical record review of endoscopic procedures, pathology reports, and abdominal imaging should always be done.

    Ask about family history of GI cancer or inflammatory bowel disease. Specific GI review of system questions include weight loss, yellow or red eyes, coughing while eating, night time diarrhea, air in urine stream, itching or yellow skin, new insomnia, and confusion.

    In summary, asking specifics regarding the presenting illness is critical to getting your patient on the correct diagnostic and therapeutic path. Spend a few minutes confirming details before ordering tests which may or may not be needed.

    GI History:

    HPI: location, severity, quality, context, association, duration, etc.

    Past medical: medical, surgical, endoscopies, and CT scans

    Allergies: medications, x-ray contrast, foods

    Medications: prescription, over the counter, and supplements

    Social: tobacco, EtOH, illicit drugs, work and travel history

    Family: GI cancers, chronic pancreatitis, Crohn’s/ulcerative colitis

    Review of Systems:

    Constitutional: weight loss, fever

    Eyes: red/yellow eyes

    ENT: mouth sores, pain on swallowing

    Respiratory: cough when eating, cough when sleeping

    Cardiovascular: chest pain with eating, lower extremity edema

    Gastrointestinal: nausea, vomiting, pain, diarrhea, bleeding- in HPI

    Genitourinary: blood/air in urine

    Musculoskeletal: joint/back pain

    Skin: yellow skin, itching, redness of

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