Gastroenterology

Gastroenterologists and physicians writing on KevinMD about digestive disease: colonoscopy and when to stop screening, celiac disease and gluten, the liver, pancreatic enzyme insufficiency, the tests marketed for leaky gut, and what patients are fed in hospitals. Board-review cases make up part of this archive. One maintained record draws on this archive: Cancer: what physicians say, in their own words.

MKSAP: 48-year-old man with a 4-week history of heartburn

mksap

Conditions and Diseases

September 11, 2018

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 48-year-old man is evaluated for a 4-week history of heartburn that awakens him at night. The symptoms occur about three times per week. He has been taking over-the-counter antacids with incomplete relief. Food triggers include coffee and spicy foods. He has not had unintentional weight loss or difficulty swallowing.

Physical examination and laboratory …

Why this gastroenterologist decided to treat hepatitis C patients

Michael Kirsch, MD

Conditions and Diseases

August 24, 2018

In a prior post, I shared my heretofore reluctance to prescribe medications for my hepatitis C (HCV) patients. In summary, after consideration of the risks and benefits of the available options, I could not persuade myself — or my patients — to pull the trigger. These patients were made aware of my conservative philosophy of medical practice. I offered every one of them an opportunity to consult with another …

MKSAP: 38-year-old woman with endometrial cancer

mksap

Conditions and Diseases

August 4, 2018

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 38-year-old woman is evaluated in follow-up after recent surgery for endometrial cancer. Her family history is significant for colon cancer in her sister (diagnosed at age 45 years) and her mother (diagnosed at age 65 years). Her maternal grandfather was diagnosed with rectal cancer at age 47 years. The patient has never …

MKSAP: 46-year-old man with intermittent rectal bleeding

mksap

Conditions and Diseases

July 24, 2018

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 46-year-old man is evaluated for intermittent rectal bleeding of 3 months’ duration. He is otherwise well and takes no medications. His father had a few polyps removed from the colon when he was 71 years old, but no other details are known about his father’s medical history. The patient and his wife …

Why medical errors can never be completely eliminated

Skeptical Scalpel, MD

Physician

July 24, 2018

A patient with progressive neurologic disorder had a gastrojejunal tube placed for feeding. In a nursing home, the tube fell out and was replaced with a Foley catheter. He was sent to the hospital for placement of a new tube. When he arrived in the interventional radiology suite, the Foley catheter was not visible. A new gastrojejunal tube was successfully placed, and the patient was sent back to the nursing …

MKSAP: 70-year-old man with heartburn

mksap

Conditions and Diseases

July 21, 2018

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 70-year-old man is evaluated in follow-up for heartburn of 7 years’ duration. He has frequent nocturnal reflux but has not had odynophagia or dysphagia, and his weight has been stable. He was recently started on once-daily omeprazole with good control of his symptoms. He has a 30-pack-year history of cigarette smoking and continues to …

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MKSAP: 70-year-old man with heartburn

The freedom to admit someone because it was the right thing to do

Hans Duvefelt, MD

Physician

July 10, 2018

The most high-powered rotation in my medical school was endocrinology. There, you got to see things most doctors never come close to diagnosing themselves. Uppsala University’s Akademiska Hospital served as a referral center for the Swedish population north of Uppsala, an area the size and shape of California.

Back in the seventies, laboratory testing wasn’t as sophisticated as it is now. We didn’t have CT scanners even at the major hospitals, …

Which of these patients should get a liver transplant?

Michael Kirsch, MD

Conditions and Diseases

July 7, 2018

People with liver failure and cirrhosis die every year because there are not enough livers available. Who should receive the treasured life-saving organ? There is an organ allocation system in place, which has evolved over time, which ranks patients who need liver transplants. Without such a system, there would be confusion and chaos. How can we fairly determine who should receive the next available liver? What criteria should move a …

It’s always easier to judge someone’s failures from higher ground

Michael Kirsch, MD

Health Policy

June 18, 2018

We’ve all heard the excuse or explanation that “it’s society’s fault,” to explain someone’s failure. We hear expressions like this often when an individual has committed a crime or simply failed to succeed. Personal accountability is diluted as we are told that this person came from an imperfect home, had no role models or ample education.

These arguments are often wielded by those who have been favored with society’s blessings and …

Colon cancer screening at age 45: Here’s what a gastroenterologist thinks

Frederick Gandolfo, MD

Conditions and Diseases

June 11, 2018

The American Cancer Society (ACS) recently released new guidelines regarding colorectal cancer screening for the average-risk individual. The big news is that they now recommend that screening for colorectal cancer begin at age 45 rather than age 50. This reduction in the starting age was in reaction to recent data showing that colon cancer is increasing in younger Americans for unclear reasons. By screening people at a younger age, the hope is …

MKSAP: 78-year-old man with symptoms of dysphagia

mksap

Conditions and Diseases

June 9, 2018

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 78-year-old man is evaluated for symptoms of dysphagia that began 2 weeks ago. When he eats, he starts coughing after the first bite of food and occasionally has nasal regurgitation.

On physical examination, blood pressure is 135/90 mm Hg, pulse rate is 78/min, and respiration rate is 12/min. Left-sided weakness is noted in both extremities, …

When the nurses’ work goes unnoticed in the ER

Raj Waghmare, MD

Physician

May 11, 2018

The two-page letter of complaint was typed on crested letterhead. The words “utter disappointment” jumped off the page, bold-faced and caps-locked. “The doctors left me to bleed,” she wrote, banging on the exclamation key as if she was firing lasers in a game of Space Invaders. “I was hemorrhaging, and they did nothing except pop in and tell me it would stop.” The tirade was directed toward me and the …

MKSAP: 38-year-old man with ulcerative colitis

mksap

Conditions and Diseases

May 5, 2018

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 38-year-old man is evaluated in follow-up after a diagnosis of ulcerative colitis. Ten days ago he was started on prednisone, 60 mg/d, but his symptoms have not improved. He has six to nine bloody bowel movements per day and moderate abdominal pain. He has decreased his oral intake because eating exacerbates his …

A surprising cause of rectal bleeding

Michael Kirsch, MD

Conditions and Diseases

May 2, 2018

“I can’t stand the site of blood!”

We’ve all heard that adage. Blood can provoke emotional reactions from even steely muscle-bound bodybuilders. We gastroenterologists routinely receive fearful phone calls from patients who have observed even minor rectal bleeding. Fortunately, in most of these cases, there is a benign explanation for the sanguinary seepage.

If blood repels you, then gastroenterology should not be on your short, or even long list of professions under …

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A surprising cause of rectal bleeding

A physician makes the case for some routine labs

Shmuel Golfeyz, MD

Conditions and Diseases

May 1, 2018

Many medical organizations have recently been promoting focused and individualized lab testing for routine screening or when pursuing a diagnosis. Research has shown that the “shotgun” approach to lab testing usually leads to further invasive testing which has not been proven to significantly alter morbidity or mortality.

Additionally, tests rely on pre-test probabilities and can have false-positive or negative results and …

The intensity of EMR warnings: Who do they really help?

Michael Kirsch, MD

Health Technology

April 22, 2018

Eons ago, there was a television show where a non-human character would yell out, “Warning, warning,” when he sensed imminent danger. The series was called Lost in Space where we were entertained by a set of quirky characters on a cheesy set. We loved that stuff. It’s hard to imagine today’s millennials and younger folks being transfixed, as we were, with the deep television dramas of our day. Who could …

A call for cost transparency

Mukul Mehra, MD

Health Policy

April 20, 2018

Physicians are the building blocks of value-based care, yet the cumulative human and financial cost of our decisions are mostly hidden from us. Instead, our reality is analogous to being on a diet and a budget at a restaurant that doesn’t put prices or calorie counts on the menu.

We need and want cost transparency. A survey from Deloitte University discovered cost is a part of …

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A call for cost transparency

The follies of health insurance preauthorization

Michael Kirsch, MD

Physician

April 10, 2018

A few weeks ago, I saw a patient some gastro issues. So far, nothing newsworthy here since I am a gastroenterologist. I ordered a CT scan colonography, a special CT scan that is designed to view the colon in detail. It’s the CT scan version of a colonoscopy. Why didn’t I simply perform a colonoscopy, which, unlike a CT scan, would contribute to my retirement fund? That’s an easy one. …

MKSAP: 41-year-old woman with burning epigastric and chest pain

mksap

Conditions and Diseases

April 7, 2018

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 41-year-old woman is evaluated in follow-up after presenting to the emergency department 1 week ago for burning epigastric and chest pain. In the emergency department, a complete blood count and liver chemistry studies were normal, but a radiograph of the chest and upper abdomen demonstrated calcified gallstones. The pain resolved with administration …

Are hepatits C drugs too expensive? Analyzing the pros and cons.

Joshua Liao, MD

Conditions and Diseases

April 5, 2018

The last few years have been marked by public outcry over the costs of novel prescription drugs, such as the hepatitis C medication sofosbuvir (brand name Sovaldi), which are highly efficacious but extremely expensive.

On the one hand, sofosbuvir produces cure rates of >90%, a figure that seemed unthinkable a few decades ago. On the other, it is priced at approximately $1000 per pill ($60,000–$90,000 for a treatment course), making it …

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