Gastrointestinal System and Nutrition
The gastrointestinal and nutrition domain tests reflux, peptic ulcer disease, pancreatitis, liver disease, inflammatory bowel disease, and nutritional deficiencies, with attention to when to test, treat, and refer.
Core rules
- GERD is diagnosed clinically when typical symptoms respond to a proton pump inhibitor. Alarm features such as dysphagia, weight loss, anemia, or vomiting require endoscopy.
- Peptic ulcer disease with Helicobacter pylori should be treated with guideline-based eradication, commonly bismuth quadruple therapy: PPI, bismuth, tetracycline, and metronidazole. Confirm eradication after treatment.
- Acute pancreatitis is diagnosed when at least two of three are present: characteristic pain, lipase greater than three times the upper limit of normal, and imaging findings. Early care is fluids, analgesia, and enteral nutrition when tolerated.
- Cirrhosis with ascites: sodium restriction, spironolactone with or without furosemide, and surveillance for varices and hepatocellular carcinoma.
Worked example
A 45-year-old has burning epigastric pain and a positive H. pylori stool antigen. He is not on a PPI. Treat with bismuth quadruple therapy for 14 days, then confirm eradication at least four weeks after antibiotics and off PPI for two weeks. Avoid clarithromycin triple therapy when local resistance is high.
Traps
- Testing H. pylori while the patient is on a PPI, causing a false-negative result.
- Missing ascending cholangitis in gallstone pancreatitis with fever and jaundice.
- Refeeding too aggressively in severe malnutrition.
- Treating irritable bowel syndrome with repeated antibiotics without indication.