Master the board step 3

Gastroenterology
Diagnostic Testing
Look for metabolic acidosis (elevated lactic acid) on blood testing and an
elevated amylase level. The most accurate test is angiography.
Treatment
If the bowel is dead, treatment is surgical resection of the bowel. Very ill patients
should go straight to the operating room for surgical resection. This is a surgical
emergency. If left undetected and untreated, the patient will die quickly. In
ischemia that is not caused by emboli, treat the underlying low flow state.
Abdominal pain out of
proportion to physical
exam = Mesenteric
ischemia
Constipation
The vast majority of cases have no clear etiology. Although Step 3 seldom
asks specifically for the diagnosis, the management of constipation involves
correcting the underlying cause. Therefore, knowing the etiology is the key to
determining the treatment. Following are possible causes of constipation:
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Dehydration: Look for decreased skin turgor in an elderly patient with an
increased BUN-to-creatinine ratio (> 20:1).
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Calcium channel blockers
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Narcotic medication use
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Hypothyroidism
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Diabetes: Loss of sensation in the bowels leads to decreased detection of
stretch in the bowel, which is one of the main stimulants of GI motility.
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Ferrous sulfate iron replacement: The stool is black and can look as though
there is upper GI bleeding. Blood is cathartic and will usually produce rapid
bowel movement. Ferrous sulfate is constipating and is also heme-negative
when one tests for occult blood.
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Anticholinergic medication: This includes tricyclic antidepressants.
Treatment with hydration and increased fiber is always a good option. You
may consider prescribing a bowel regimen with Senokot and docusate.
Dumping Syndrome
Dumping syndrome is a relatively rare disorder related to prior gastric surgery,
usually done for ulcer disease. Treatment and eradication of Helicobacter
pylori has made surgery for ulcer disease rare.
The patient presents with shaking, sweating, and weakness.
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