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: 57-year-old man with chronic hepatitis C infection

mksap

Conditions and Diseases

March 31, 2018

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

A 57-year-old man is evaluated during a routine examination. His medical history is notable for chronic hepatitis C infection with cirrhosis, which was diagnosed 3 years ago. He undergoes surveillance ultrasound for hepatocellular carcinoma every 6 months.

On physical examination, temperature is 36.8 °C (98.2 °F), blood pressure is 110/82 mm Hg, pulse rate …

What you should know about colon polyps

Frederick Gandolfo, MD

Conditions and Diseases

March 22, 2018

When it comes to colon cancer prevention, the polyp is the key player to know. Colon polyps, called adenomas, are precancerous growths originating from the inner lining of the colon wall. There are other types of polyps in the colon which are not considered precancerous, but for our purposes in this article, we will consider the terms colon polyp and adenoma to be …

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What you should know about colon polyps

Doing too much hurt this patient

Raj Waghmare, MD

Conditions and Diseases

March 15, 2018

It’s early March. I walk quickly past the ambulance bay, shivering as the doors open. Paramedics push a stretcher into the hall as a limp body gasps for air.

“Doc,” the tired man says. “I need help.”

“What happened?” I say. “You look terrible.”

“My belly is killing me.” He grips his stomach. ”I’m going to pass out.”

His pulse is weak, his hands cold. A nurse inserts an IV and turns to me: …

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Doing too much hurt this patient

MKSAP: 67-year-old woman with degenerative joint disease

mksap

Conditions and Diseases

March 3, 2018

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

A 67-year-old woman is evaluated during a routine examination. She has a history of hip and knee pain related to degenerative joint disease. The joint pain is now well controlled with diclofenac, which was started 3 months ago. A previous trial of high-dose acetaminophen was not effective. She does not have any gastrointestinal …

Fixation error can be deadly in medicine

Raj Waghmare, MD

Conditions and Diseases

February 26, 2018

John Grover is a nice guy. He’s fifty-five, short, a little chubby, and he has a neatly trimmed red beard. He’s the kind of guy whose eyes light up the moment you walk into the room; The kind of guy who remembers your kids’ names, their ages, and their interests. I’d met him a few times before. He’d come in once to refill his blood pressure medication because he couldn’t …

How an annual physical combined with unnecessary testing doesn’t help

Samuel Harrington, MD

Physician

February 26, 2018

Some would argue that more care for the elderly is …

It’s time to treat C. diff diarrhea

Eric R. Gottlieb, MD

Conditions and Diseases

February 20, 2018

For millennia, blood-letting was the standard of care for many diseases; today it is a joke, evoked only to mock our predecessors. But it is time to dismount our high horse and realize that there is at least one infection that we still primitively try to drain from the body, not from the bloodstream, but from the colon. This is our friend Clostridium difficile.

According to the CDC, there are about …

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It’s time to treat C. diff diarrhea

MKSAP: 55-year-old woman after bariatric surgery

mksap

Conditions and Diseases

January 20, 2018

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

A 55-year-old woman is evaluated during a routine examination. She underwent biliopancreatic diversion with duodenal switch 8 years ago for treatment of obesity-related complications and lost 68.0 kg (150.0 lb) in the first year following surgery. Her weight has been relatively stable for the last year. She has had chronic nonbloody diarrhea since her bariatric …

Learn about Clostridium difficile infection with a Medcomic

Jorge Muniz, PA-C

Conditions and Diseases

January 8, 2018

Clostridium difficile is a gram-positive anaerobic bacillus which secretes toxins (A and B) that cause diarrhea and pseudomembranous colitis. C. difficile is the most common infectious cause of nosocomial diarrhea. Transmission of C. difficile can occur from contact with contaminated humans and fomites. The organism contains endospores that can survive the acidity of the stomach and reach the large intestine.

C. difficile colonizes the intestinal tract after the normal …

Is autonomy really better for patients?

Michael Kirsch, MD

Physician

December 15, 2017

It used to be that doctors knew best. We told you what to do, and you obediently complied. The world has changed, and the paternalistic system of yore has given way to the shared decision model where patient autonomy is respected.

The old way: “Well, I’ll be setting you up for surgery soon.”

The new and improved way: “Let’s discuss all of the reasonable options with their respective advantages and drawbacks. Then, …

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Is autonomy really better for patients?

MKSAP: 22-year-old woman is evaluated for a flare of Crohn disease

mksap

Conditions and Diseases

December 9, 2017

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

A 22-year-old woman is evaluated for a flare of Crohn disease. A colonoscopy performed 6 months ago showed moderate, patchy, left-sided colitis extending from the descending colon to the splenic flexure. She responded to therapy with prednisone but declined maintenance therapy in advance of conceiving. She is now 12 weeks pregnant and …

A first-time case in a 35-year medical career

Hans Duvefelt, MD

Conditions and Diseases

December 8, 2017

A couple of years ago I saw a young man with pain in his lower right abdomen. I sent him for an urgent CT scan with a “wet read” to check for appendicitis.

It was afternoon, and things were crazy at the office. I forgot all about the pending CT report. I have learned this about myself: I am efficient because I have the ability to hyperfocus, but that has made …

When EMRs crash: It’s time to push back

Michael Kirsch, MD

Health Technology

December 3, 2017

The computerized era has introduced all of us to a genre of errors that never existed during the archaic pen and paper era. The paper medical chart I used during most of my career never “crashed.” Now, when our electronic medical records (EMR) freezes, malfunctions, or simply goes on strike, our office is paralyzed. Although I appear to the patients as a breathing and willing medical practitioner, I might as …

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When EMRs crash: It’s time to push back

MKSAP: 25-year-old man positive for hepatitis B surface antigen

mksap

Conditions and Diseases

December 2, 2017

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

A 25-year-old man is evaluated in follow-up after recently testing positive for hepatitis B surface antigen. He underwent testing as part of the immigration process from Somalia. Two other siblings also have hepatitis B virus (HBV) infection.

On physical examination, he is a young, healthy-appearing man. Vital signs are normal. No jaundice is …

Do medical experts really know best?

Stephen C. Schimpff, MD and Harry Oken, MD

Conditions and Diseases

November 30, 2017

“In the beginner’s mind there are many possibilities, but in the expert’s view, there are few.”

Shunryu Suzuki was writing about Zen beginners and masters, but this concept applies to the practice of medicine as well. Experienced physicians are slow to accept a new paradigm, while medical students and new physicians are more open.

Sometimes, what we “know” to be true is not. Despite clinical trials to the …

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Do medical experts really know best?

Is there danger in hoping too much?

Darrel Moellendorf

Patient

November 27, 2017

According to Hesiod’s version of an ancient Greek legend, because Pandora has opened a jar stuffed full of evil by the Olympian gods, “countless plagues, wander amongst men … earth is full of evils … Diseases come upon men continually by day and by night, bringing mischief to mortals silently.” Curiously that jar was closed before hope was also allowed to escape.

Is the legend an expression of how bleak the …

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Is there danger in hoping too much?

Who’s responsible for polypharmacy in the elderly?

Michael Kirsch, MD

Medications

November 20, 2017

There’s a common affliction that’s rampant in my practice, but it’s not a gastrointestinal condition. It’s called polypharmacy, and it refers to patients who are receiving a pile of prescription and other medications. I see this daily in the office and in the hospital. It’s common enough to see patients who are receiving 10 or more medications, usually from 3 or 4 medical specialists.

Of course, every doctor feels that he …

Colonoscopy after a positive stool test: Does the time frame matter?

Richard Young, MD

Conditions and Diseases

November 10, 2017

There are some questions in health care that can’t be answered with a randomized controlled trial. We can’t randomize babies to inhale secondary tobacco smoke or not to test its health effects. We can’t randomize people to a different number of hours sitting the ER before receiving antibiotics after the decision is made that the patient has a bacterial infection requiring antibiotics. There are some questions where the best available …

Burnout during residency? Yep, and here’s what it taught me.

Saba Mann, MD

Physician

November 9, 2017

You’ve probably heard this story before: a young physician, who has spent all of his or her life succeeding and building goals, stumbles into a career without meaning or enthusiasm. Indeed, my story about burnout is much like the rest.

Like so many before me, I entered into a career in medicine motivated and eager to change the world through the care of my patients. I grew up in a family …

MKSAP: 35-year-old man with upper abdominal discomfort

mksap

Conditions and Diseases

November 4, 2017

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

A 35-year-old man is evaluated for a 2-month history of upper abdominal discomfort after eating. He has recently returned from working in a rural area of a developing country. He takes no medications. There is no family history of esophageal or gastric cancer.

On physical examination, vital signs are normal. BMI is 40. …