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

Podcast #70: Pancreatic Injuries

a1645dd1-d162-4754-b565-6979540a068aRun Time: 3 minutes

Author: Dr. Brent Levy

Educational Pearls:

  • Pancreatic injuries are generally associated with blunt trauma and high velocity causing compression of the pancreas into the spine.
  • 3-5% of intra-abdominal trauma injuries involve the pancreas.
  • CT scans are not very effective in diagnosing a pancreatic injury. A clinical diagnosis usually comes from relating history with persistent unexplained abdominal pain coupled with possibly an elevated lipase. If there is high suspicion, an ERCP or an MRCP can be performed.
  • Pancreatic injuries, regardless of the timeline of diagnosis, have a high morbidity and mortality rate. These patients often develop pseudocysts, abscess, can have pancreatic death.
  • There are four grades of pancreatic injury. 1 and 2 are managed by NPO status, fluids, and pain medication. 3 and 4 have to do with disruption of the pancreatic tail or complete obliteration of the pancreas.

Link to Podcast:  http://medicalminute.madewithopinion.com/pancreatic-injuries/

References:  http://www.ncbi.nlm.nih.gov/pubmed/12079266

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3870553/

Podcast #65: Intussusception

Run Time: 2 minutesdbfbdcad-54ed-4b8e-91a1-6d4f51fb8784

Educational Pearls:

  • Intussusception is when the intestines telescope in on each other. This condition is idiopathic and occurs most in children of the age six months to two years.
  • The child usually presents with intermittent abdominal pain, vomiting, diarrhea, URI, abdominal distention, and lethargy. As the bowel dies, the child also can have a “currant jelly stool.”
  • Treatment is usually reduction of the bowel done through an air enema, if this does not work or the bowel is perforated the child usually needs surgery.

Link to Podcast: http://medicalminute.madewithopinion.com/intususseption/

References:  http://www.ncbi.nlm.nih.gov/pubmed/21415671

Podcast #51: Diverticulitis

Run Time: 3 minutesdiverticulitis_s3_conditions

Author: Dr. Michael Hunt

Educational Pearls:

  • Diverticulitis is the inflammation of diverticula or projecting pockets coming off of the colon.
  • 2-4% of the population have this and 15-30% have recurrences of diverticulitis. Most of these cases do not have any complications.
  • Flagyl and ciprofloxacin are given normally to treat the infection in the United States. This can cause antibiotic related complications like Clostridium difficile.
  • Certain European countries have altered their treatment plan to not prescribe antibiotics for non-complicated diverticulitis.
  • The criteria for non-complicated are: health, no white count, no sepsis, no perforation, no abscess, and no peritonitis.

Link to Podcast: http://medicalminute.madewithopinion.com/diverticulitis/


References: 
http://www.ncbi.nlm.nih.gov/pubmed/27053254

 

Podcast #30: Pancreatitis

78f5bb22-2440-4cb7-88b5-80c61ea2d4cbRun Time: 5 minutes

Author: Dr. Samuel Killian

Educational Pearls:

  • Acute pancreatitis care can be very different from someone with chronic pancreatitis – mortality rate is high at 6-10% for acute pancreatitis.
  • 90% of pancreatitis cases are from alcohol and biliary disease. The remainder of cases are from medication, auto-immune, trauma, hyperlipidemia, and idiopathic causes.
  • True diagnosis of pancreatitis needs 2-5 times the normal lipase level – appendicitis and trauma may elevate lipase level.
  • Signs of significant dehydration, significant hypoperfusion, or any evidence of SIRS criteria generally indicated that a patient will become very sick.
  • There are multiple scoring systems for admission and treatment options – Ranson’s criteria, APACHE 2 criteria.

Link to Podcast:  http://medicalminute.madewithopinion.com/pancreatitis/

References:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886461/

Podcast #27: Variceal Upper GI bleed


d5b78f1e-01d8-4532-9460-b98af671d6baRun Time: 9 minutes

Author: Dr. Donald Stader

Educational Pearls:

  • Patients with variceal bleeding are sick at baseline, and come from a very sick patient population with a higher mortality rate.
  • Varices occur in a patient with cirrhosis when blood goes through other pathways to get back to the heart – rather than going through the liver.
  • Antibiotics help greatly with survival of a variceal bleeder because bacteria translocate from the stomach to the blood.
  • If a patient has a Sengstaken-Blakemore tube placed the patient has a high morbidity. If the patient makes it to the ICU a tips procedure is done – a shunt of the liver w/ a catheter that goes around liver and back to the heart.
  • If a blood transfusion is given before the pt is in hemorrhagic shock – hemoglobin <7 – the patients mortality rate is increased due to the potential to give the patient and infection.

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

References:  http://gi.org/guideline/prevention-and-management-of-gastroesophageal-varices-and-variceal-hemorrhage-in-cirrhosis/