Rotation:
Gastroenterology Subspecialty Selective
Goals:
1) Provide medical residents and students with knowledge necessary to evaluate and treat common GI complaints that primary care physicians are likely to face in practice including dysphagia, heartburn, nausea and vomiting, abdominal pain, diarrhea, constipation, gastrointestinal bleeding, jaundice and ascites.
2) Describe how a GI subspecialist approaches common and complex GI disorders and how they use available diagnostic tools to manage and treat the disorders.
Objectives:
1) Develop the basic medical knowledge to evaluate and treat the following GI complaints: dysphagia, heartburn, nausea and vomiting, abdominal pain, diarrhea, constipation, GI bleeding, jaundice and ascites.
2) Provide competent patient care - data acquisition, diagnosis, and management - for patients with GI complaints.
3) Demonstrate practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice through interaction with patients, attendings and other health care personnel and through delivery of conscientious subspecialty care in a variety of venues.
OPTIONAL:
4) Under supervision perform 25 or more flexible sigmoidoscopies to a depth of 60+ cm recognizing common colorectal pathology (hemorrhoids, polyps, and cancer).
Learning Venues:
A. In-patient GI Consultation Services will form the anchor of the rotation. Residents will obtain histories and perform physical examinations on patients with GI disorders and present them daily on attending rounds. Learning will be primarily case-based and patient-centered.
B. Out-patient GI and Hepatology Clinics with exposure to patients with GI problems in the ambulatory setting. Emphasis will be on patients presenting with new complaints so that initial evaluation, diagnostic work-up, and management can be stressed. Exposure to patients with chronic GI complaints who are returning for follow-up will also be provided. Learning in this venue will also be primarily case-based and patient centered.
C. GI Endoscopy Labs at the Saint Mary’s Health Center will provide residents with exposure to the technical aspects of gastroenterology. Residents are required to observe all endoscopic procedures performed on in-patients that they have seen in consultation. This allows for clinical correlation between patient symptoms and actual GI pathology. Residents are also encouraged to observe as many different endoscopic procedures they can to appreciate the advantages and disadvantages, risks and benefits of routine endoscopy. For residents interested in learning how to perform flexible sigmoidoscopy, hands-on training will be provided (this is optional). Documentation of a minimum of 25 supervised procedures and approval by a staff endoscopist following observation of a performed procedure is required to obtain a letter certifying competence.
D. Reading materials will be provided at the beginning of each rotation. The syllabus
provided will span the broad spectrum of GI and liver disorders and will cover topics that
may not present themselves in the in-patient or outpatient teaching venues. It will be
comprised mostly of NEJM review articles, aimed at the internist rather than the
subspecialist. The resident is expected to read each of these articles during the month rotation (~1 article per day). Exam questions will come from information in these articles.
E. Didactic teaching sessions will be used to supplement the educational experience. These include GI and hepatology journal clubs, pathology
conferences, and noon conferences. Residents are
required to attend these conferences depending on the site.
READING LISTS:
Required Reading (PROVIDED)
1. GI bleeding
Lower gastrointestinal bleeding. Dis Colon Rectum. 40:846-58. 2001.
Occult gastrointestinal bleeding. NEJM341:38-46, 1999.
2. Peptic ulcer disease
Medical treatment of peptic ulcer disease JAMA 275:622-29, 1996.
3. GERD and dysphagia
Medical, surgical, and endoscopic treatment of gastroesophageal reflux disease
and Barrett's esophagus. J Clin Gastroenterol. 33(4):262-6, 2001.
4. Constipation
Constipation: evaluation and management, Prim. Care 28:577-590, 2001.
5. Diarrhea
Evaluation of patients with chronic diarrhea. NEJM332:725-729, 1995
Antibiotic-associated diarrhea, NEJM 346:334-339, 2002.
6. IBD
Inflammatory bowel disease. NEJM 347:417-429,2002.
7. Gut Dysmotility
The irritable bowel syndrome, NEJM 344:1846-1850, 2001.
8. GI neoplasia
Chemoprevention of colorectal cancer NEJM 342: 1960-1968, 2000.
Screening for colorectal cancer, NEJM 346:40-44, 2002.
9. Nutrition
Nutritional support. NEJM336:41-48, 1997.
10. Pancreatic diseases
Chronic pancreatitis. NEJM 332: 1482-90, 1995
Acute necrotizing pancreatitis. NEJM 340: 1412-17, 1999
11. Biliary tract disease
Pathogenesis and treatment of gallstones. NEJM 328:412-421, 1993
12. Alcoholic liver dz.
Pathogenesis, diagnosis, and treatment of alcoholic liver disease. Mayo Clin Proc.
76:1021-9,2002
13. Non-alcoholic liver diseases.
Nonalcoholic fatty liver disease, NEJM 346: 1221-1231, 2002.
Autoimmune hepatitis. NEJM 334:897-903, 1996
Hemochromatosis: diagnosis and management. Am Fam Physician 53:2623-32, 1996
14. Viral hepatitis
Serologic diagnosis of viral hepatitis. Med. Clin. North Am. 80:929-959, 1996
Treatment of chronic viral hepatitis. NEJM 336:347 -56, 1997.
15. Complications of Portal hypertension
Current management of the complications of cirrhosis and portal hypertension:
variceal hemorrhage, ascites, and spontaneous bacterial peritonitis,
Gastroenterol. 120:726-48, 2001.
16. Liver Transplantation
Acute liver failure, J Clin Gastroenterol.33 (3): 191-8. 2001.
Supplemental Reading
1. GI bleeding
Endoscopy of the upper GI tract. NEJM 341: 1738-48, 1999
2. Peptic ulcer disease
The Helicobacter pylori genome - new insights into pathogenesis and therapeutics,
NEJM338:832-833, 1998.
3. GERD and dysphagia
The esophagogastric junction. NEJM336:924-932, 1997.
GERD management. Strategies recommended for primary care practice, Postgrad
Med. Spec No:11-8, 2001.
Noncardiac chest pain, J Clin Gastroenterol.34(1):6-14, 2002.
Barrett's Esophagus, NEJM 346:836-842, 2002.
4. Diarrhea
Diarrhea in patients with AIDS. Gastro 105: 1238-42, 1993
Prevention and treatment of travelers diarrhea. NEJM 328:1821-1826, 1993
E. coli 0157:H7 and the hemolytic uremic syndrome. NEJM333:364-368, 1995
5. IBD
Extraintestinal manifestations of idiopathic inflammatory bowel disease. Arch Intern Med
148:297-302, 1988.
6. Gut Dysmotility
Gastrointestinal motility disorders. Am. Fam. Physician 53:895-902, 1996
7. GI neoplasia
Hereditary gastrointestinal polyposis and nonpoyposis syndromes, NEJM 331 :1694- ,
1702,1994
Chemoprevention of colorectal cancer NEJM 342: 1960-1968, 2000.
Gastric carcinoma. NEJM333:32-41, 1995
Pancreatic cancer. NEJM326:455-464, 1992
8. Biliary tract disease
Pancreatic and biliary endoscopy. NEJM 341 : 1808-16, 1999
Biliary tract cancers. NEJM 341: 1368- 78, 1999
9. Non-alcoholic liver diseases.
Primary sclerosing cholangitis. NEJM332:924-33, 1995
Primary biliary cirrhosis NEJM335:1570-1580, 1996
Wilson's Disease: current status. Am J Med 92:643-54, 1992
Alpha-I-antitrypsin deficiency and liver disease. Dig Dis Sci 12:139-49, 1994.
10. Viral hepatitis
Serologic diagnosis of viral hepatitis. Med. Clin. North Am. 80:929-959, 1996
Treatment of chronic viral hepatitis. NEJM 336:347 -56, 1997.
Hepatitis B virus infection. NEJM337:1733-1744, 1997
Hepatitis C virus infection, NEJM 345:41-52, 2001.
11. Complications of Portal Hypertension
Gastroesophageal variceal hemorrhage, NEJM 345 :669-681, 2001.
Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a
consensus document, J Hepatol. 32:142-53,2000.
Pathogenesis and treatment of fluid and electrolyte imbalance in cirrhosis., Semin
Nephrol. 21:308-16, 2001.
Hepatorenal syndrome, Clin Liver Dis. 4:487-507,2000.
Complications of cirrhosis. Hepatic encephalopathy. J Hepatol.32(1 Suppl):171-
80, 2000.
Treatment of hepatic encephalopathy. NEJM337:473-80, 1997.
Management of ascites, Clin Liver Dis.5:541-68, 2001.
Ascitic fluid analysis: the role of biochemistry and hematology, Hosp Med.
62(5):282-6,2001.
The role of TIPS for treatment of portal hypertension and its complications.
Hepatology 22:1591-7, 1995.
12. Liver Transplantation
Liver transplantation. who should be referred and when. Postgrad Med 102: 103-113,
1997
Primary care management of the liver transplant patient. Am. J. Med. 96: 10S-17S, 1994
Fulminant hepatic failure, Clin Liver Dis. 4:25-45. 2000.
13. Pediatric liver disease
Current concepts in diagnosis and therapy of pediatric liver diseases. J Hepatol23
Suppl 1 :45-8, 1995
14. Liver Malignancies
Primary liver cancers. Curr Opin Oncol (US) 7:387-96, 1995.
Competency Evaluation:
ABIM Global Assessment Form - All six competencies must be rated as satisfactory or superior. Written examination at end of rotation - to assess medical knowledge and patient care, 80% must be correct.
Outcomes Assessment:
The educational success of our elective in gastroenterology will be based on two criteria:
(1) GI subsections scores on the in-service examination of all residents who have successfully complete the elective and (2) GI subsections scores on the ABIM certifying examination in internal medicine taken by medical graduates. Our goal is all residents scoring at the 50th percentile or higher.