Podcast #307: Guillain-Barre Syndrome

Author: Peter Bakes, M.D.

Educational Pearls:

  • Rare disease with 1-2 patients out of 100,000. About 60% of patients report a preceding diarrheal illness and classically presents with an ascending motor weakness.
  • Pathophysiology is likely due to molecular mimicry where the immune system creates antibodies against a pathogen (C. jejuni ) which appears similar to the myelin of peripheral nerves resulting in autoimmune demyelination.
  • Diagnosis is made by clinical presentation +/- a spinal tap with a characteristic high protein count but without cells.
  • Treatment is IVIG or plasmapharesis. It is important to monitor respiratory function because about 15% of patients progress to respiratory failure.



Sejvar, James J.; Baughman, Andrew L.; Wise, Matthew; Morgan, Oliver W. (2011). “Population incidence of Guillain?Barré syndrome: a systematic review and meta-analysis”

van den Berg, Bianca; Walgaard, Christa; Drenthen, Judith; Fokke, Christiaan; Jacobs, Bart C.; van Doorn, Pieter A. (15 July 2014). “Guillain?Barré syndrome: pathogenesis, diagnosis, treatment and prognosis”. Nature Reviews Neurology. 10 (8): 469?482.

Yuki, Nobuhiro; Hartung, Hans-Peter (14 June 2012). “Guillain?Barré Syndrome”. New England Journal of Medicine. 366 (24): 2294?2304.

Podcast #301: Biliary Pathology

Author: Don Stader, M.D.

Educational Pearls

  • Common pathologies include cholecystitis, choledocholithiasis, and in concerningly ascending cholangitis.
  • Cholecystitis is obstruction at the cystic duct leading to inflammation of gallbladder wall, while choledocholithiasis is a distal obstruction of the biliary tree, and ascending cholangitis is an ascending infection of the biliary tree secondary to obstruction.
  • Risk factors for Cholecystitis are the 5 F’s (Fat, Forty, Female, Fertile, Family Hx).
  • Classic symptoms seen in ascending cholangitis are Charcot’s Triad of fever, RUQ pain, and jaundice, or Reynold’s pentad which is more severe and has the addition of
    altered mental status and hypotension.
  • Porcelain gallbladder is a radiographic finding showing calcification of the gallbladder that is associated with cancer of the gallbladder.


Kimura Y, Takada T, Kawarada Y, et al. (2007). “Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines”. J Hepatobiliary Pancreat Surg.

Strasberg, SM (26 June 2008). “Clinical practice. Acute calculous cholecystitis”. The New England Journal of Medicine. 358 (26): 2804?11.

Podcast #289: Cannabinoid Hyperemesis

Author: Dylan Luyten, M.D.

Educational Pearls

  • Cannabinoid Hyperemesis syndrome is a relatively new diagnosis that presents with vomiting and abdominal pain without a clear etiology in the setting of daily marijuana use.
  • The pathophysiology is not well-understood well, but may involve cannabinoid receptors in the gut.
  • Treatment is abstinence from marijuana, fluids, dextrose, and antiemetics (haldol, ondansetron, etc). Opioids should be avoided.
  • Capsaicin cream on the abdomen may be helpful, as it can distract from the pain and vomiting. Milk can be used to reverse its effects.

References:  Galli JA, Sawaya RA, Friedenberg FK. Cannabinoid Hyperemesis Syndrome. Current drug abuse reviews. 2011;4(4):241-249.

Podcast #288: Diarrhea

Author: Peter Bakes, M.D.

Educational Pearls

  • Chronic diarrhea is defined as 3 or more loose, watery stools lasting more than 2-3 weeks.
  • Look for clues in the history, including  travel (could suggest infectious etiology), antibiotic use (could suggest C. Diff), and family history.
  • Irritable Bowel Disease (Crohn’s/Ulcerative Colitis) is an autoimmune disorder that affects 1.3 million Americans and is a leading cause of chronic diarrhea.
  • Crohn’s always involves the terminal ileum, but can present anywhere along the GI tract. It causes transmural inflammation of the bowel wall and can lead to adhesions, perforations, and fistulas. Ulcerative colitis usually involves the rectum and causes mucosal inflammation only.
  • Workup for IBD includes colonoscopy and tissue biopsy.
  • Treatment for IBD includes dietary changes, 5-ASA/Mesalamine, steroids, and infliximab (anti-TNF alpha).

References:  https://www.aafp.org/afp/2011/1115/p1119.html

Podcast #285: C Diff

Author: Aaron Lessen, M.D. 

Educational Pearls

  • While C. difficile infections are generally thought of as nosocomial, there is a subset of patients who acquire the infection in the community.
  • One recent study showed that about 10% of patients presenting to the ED with diarrhea and without vomiting had a C. diff infection.
  • Another study found risk factors for community-acquired C. diff included recent ED/Urgent care visits and antibiotic use. However, 36% of the patients in that study had no identifiable risk factors.

References:  Gupta A, Khanna S. Community-acquired Clostridium difficile infection: an increasing public health threat. Infection and Drug Resistance. 2014;7:63-72. doi:10.2147/IDR.S46780.

Podcast #239: GERD vs. MI

Author: Dave Rosenberg, M.D.

Educational Pearls

  • MI and GERD can present similarly. For example, 47% with angina report increased belching with an anginal attack, and 20% of people with an MI describe symptoms  of indigestion that are relieved by antacids.
  • Overall, GERD is more common in those with CAD, so don’t be “reassured” by GERD symptoms in the setting of chest pain.

References: http://www.mdedge.com/ecardiologynews/article/82215/cad-atherosclerosis/gerd-may-boost-risk-mi

Podcast #231: Esophageal Tearing

Author: Jared Scott, M.D.

Educational Pearls

  • Boerhaave syndrome (aka effort rupture of the esophagus) accounts for 10% of esophageal ruptures and is usually caused by strain during vomiting episodes. It can also be caused by childbirth, seizure, or prolonged coughing or laughing.  
  • Food and water swallowed after the tear end up in the mediastinum, eventually causing infection. Therefore, Boerhaave syndrome is a surgical emergency.
  • Best diagnostic techniques are CT or endoscopy.
  • Mallory-Weiss syndrome may present similarly, however it is less serious since it involves only a small tear through the mucosa at the gastroesophageal junction. This can be managed on an outpatient basis with PPI’s.

References: https://radiopaedia.org/articles/boerhaave-syndrome

Podcast #177: Rectal Prolapse

imageRun Time:  3 minutes

Author: Jared Scott M.D.

Educational Pearls:

  • The true incidence of rectal prolapse is unknown because patients, understandably, under report.
  • Rectal prolapse is most common in patients between 40-70s, but children generally under the age of 3 can have rectal prolapse as well.
  • Women older than 50 are 6 times more likely to have rectal prolapse, but 35% of those patients have never had children. In males there is usually an underlying bowel dysfunction.
  • Applying sugar to prolapsed rectum acts as a desiccant and takes out some of the tissue edema, which reduces the size of the prolapse and helps reduce the rectum.
  • Theoretically any desiccant can be used, but most case reports suggest sugar. Desiccants can also be used to reduce colostomies and ileostomies.

Link to Podcast: http://medicalminute.madewithopinion.com/rectal-prolapse/

References: http://emedicine.medscape.com/article/2026460-overview

Podcast #147: GI Bleed – 1966

a20e0189-4563-441d-a603-20ea49b3652cRun Time: 6 minutes

Author: Chris Holmes M.D.

Educational Pearls:

  • There was a 50% mortality rate from upper GI bleeds and 20% of cases were unrecognized.
  • Management: The thought was that every patient had peptic ulcer disease or variceal bleeding.
  • First check for liver disease with the bromosulfophthalein excretion test – does not work for people with GI bleed. Then perform a splenoportogram – inject the pt with contrast dye and have enthusiastic radiologist view the images, simultaneously hook up the patient to a manometer, if the splenic pressure is greater than 300 the patient probably had liver disease and variceal bleeding.
  • Patients were also subject to a rigid endoscopy, which was state of the art and was just beginning to be practiced clinically.
  • Patients were also given a Levine tube with ice and saline solution irrigation.
  • Fresh blood was administered & neomycin was given to everyone.
  • Surgery was another mainstay of treatment. Patients were given a Blakemore tube and it was left in for 2 days.
  • There were no H2 blockers, tagamet came out in approximately 1980. No PPIs, so antacids every 1 hour given through the blakemore tube included calcium carbonate alternating with milk.

Link to Podcast: http://medicalminute.madewithopinion.com/gi-bleed-1966/

References: http://www.thennt.com/nnt/proton-pump-inhibitors-for-acute-upper-gi-bleeding/

Podcast #115: Clostridium Difficile

7e71490a-0559-4f13-a051-1af08c2f3366Run Time: 2 minutes

Author: Aaron Lessen M.D.

Educational Pearls:

  • One of the big causes of C. diff infection in patients is antibiotics because they destroy the beneficial bacteria in the intestines, which, allows C. diff to run rampant and lead to infection.
  • Different antibiotics have different likelihoods of leading to a C. diff infection:
    • One of the worst is Clindamycin – which is 16 times more likely to result in a C. diff infection.
    • Other bad antibiotics: Quinolones – 5 times more likely to result in infection – (Cipro/Levaquin), broad spectrum Cephalosporins, Carbapenems.
    • Antibiotics that are not as bad: Macrolides, Bactrim, Doxycycline, and Penicillins.
  • There is some evidence that probiotics potentially can decrease the chance of C.diff infection.

Link to Podcast: http://medicalminute.madewithopinion.com/clostridium-difficile/

References: http://www.clinchem.org/content/62/2/310.long