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