i A First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer, Editors ii Disclaimer: Neither the author(s) nor CAPStone Academic Publishers can ensure the accuracy of the information contained in these books with regards to regional variations for recommended indications, dosages, and reportable adverse events. With the rapid expansion of medical knowledge, there may be, from time to time, variations between what is published in these books and the latest information and consensus recommendations made by different organizations. It is the responsibility of the reader to confirm independently any practice decisions related to an individual patient. iii First Principles of Gastroenterology and Hepatology CAPstone (Canadian Academic Publishers Ltd) is a not-for-profit company dedicated to the use of the power of education for the betterment of all persons everywhere. “The Democratization of Knowledge” 2012 This book is endorsed by The Canadian Association of Gastroenterology, and The Canadian Association for the Study of the Liver First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer iv First Principles and the CANMED Objectives Medical expert The discussion of complex cases provides the participants with an opportunity to comment on additional focused history and physical examination. They would provide a complete and organized assessment. Participants are encouraged to identify key features, and they develop an approach to problem-solving. The case discussions, as well as the discussion of cases around a diagnostic imaging, pathological or endoscopic base provides the means for the candidate to establish an appropriate management plan based on the best available evidence to clinical practice. Throughout, an attempt is made to develop strategies for diagnosis and development of clinical reasoning skills. Communicator The participants demonstrate their ability to communicate their knowledge, clinical findings, and management plan in a respectful, concise and interactive manner. When the participants play the role of examiners, they demonstrate their ability to listen actively and effectively, to ask questions in an open-ended manner, and to provide constructive, helpful feedback in a professional and non-intimidating manner. Collaborator The participants use the “you have a green consult card” technique of answering questions as fast as they are able, and then to interact with another health professional participant to move forward the discussion and problem solving. This helps the participants to build upon what they have already learned about the importance of collegial interaction. Manager Some of the material they must access demands that they use information technology effectively to access information that will help to facilitate the delineation of adequately broad differential diagnoses, as well as rational and cost effective management plans. Health advocate In the answering of the questions and case discussions, the participants are required to consider the risks, benefits, and costs and impacts of investigations and therapeutic alliances upon the patient and their loved ones. Scholar By committing to the pre- and post-study requirements, plus the intense three day active learning Practice Review with colleagues is a demonstration of commitment to personal education. Through the interactive nature of the discussions and the use of the “green consult card”, they reinforce their previous learning of the importance of collaborating and helping one another to learn. First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer v Professional The participants are coached how to interact verbally in a professional setting, being straightforward, clear and helpful. They learn to be honest when they cannot answer questions, make a diagnosis, or advance a management plan. They learn how to deal with aggressive or demotivated colleagues, how to deal with knowledge deficits, how to speculate on a missing knowledge byte by using first principals and deductive reasoning. In a safe and supportive setting they learn to seek and accept advice, to acknowledge awareness of personal limitations, 0 and to give and take 360 feedback. Knowledge The basic science aspects of gastroenterology are considered in adequate detail to understand the mechanisms of disease, and the basis of investigations and treatment. In this way, the participants respect the importance of an adequate foundation in basic sciences, the basics of the design of clinical research studies to provide an evidence-based approach, the designing of clinical research studies to provide an evidence-based approach, the relevance of their management plans being patient-focused, and the need to add “compassionate” to the Three C’s of Medical Practice: competent, caring and compassionate. “They may forget what you said, but they will never forget how you made them feel.” Carl W. Buechner, on teaching. “With competence, care for the patient. With compassion, care about the person.” Alan B. R. Thomson, on being a physician. First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer vi Prologue HREs, better known as, High Risk Examinations. After what is often two decades of study, sacrifice, long hours, dedication, ambition and drive, we who have chosen Internal Medicine, and possibly through this a subspecialty, have a HRE, the [Boards] Royal College Examinations. We have been evaluated almost daily by the sadly subjective preceptor based assessments, and now we face the fierce, competitive, winner-take-all objective testing through multiple choice questions (MCQs), and for some the equally challenging OSCE, the objective standardized clinical examination. Well we know that in the real life of providing competent, caring and compassionate care as physicians, as internists, that a patient is neither a MCQ or an OSCE. These examinations are to be passed, a process with which we may not necessarily agree. Yet this is the game in which we have thus far invested over half of our youthful lives. So let us know the rules, follow the rules, work with the rules, and succeed. So that we may move on to do what we have been trained to do, do what we may long to do, care for our patients. The process by which we study for clinical examinations is so is different than for the MCQs: not trivia, but an approach to the big picture, with thoughtful and reasoned deduction towards a diagnosis. Not looking for the answer before us, but understanding the subtle aspects of the directed history and focused physical examination, yielding an informed series of hypotheses, a differential diagnosis to direct investigations of the highly sophisticated laboratory and imaging procedures now available to those who can wait, or pay. This book provides clinically relevant questions of the process of taking a history and performing a physical examination, with sections on Useful background, and where available, evidence- based performance characteristics of the rendering of our clinical skills. Just for fun are included "So you want to be a such-and-such specialist!" to remind us that one if the greatest strengths we can possess to survive in these times, is to smile and even to laugh at ourselves. Sincerely, Emeritus Distinguished University Professor, University of Alberta Adjunct Professor, Western University First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer vii Dedication Without the caring support from our families for our academic work, the meaning of our accomplishments would disappear. th To Cecille Aumont and Kervin Mineault, who taught us what it meant to be a 15 generation Canadien. Je me souviens. And to Noah and Zoe (Shaffer Gordon) and Jasper and Macy (Shaffer Nash) who represent the st future in this 21 century. A.B.R. Thomson E. A. Shaffer First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer viii Acknowledgements Patience and patients go hand in hand. So also does the interlocking of young and old, love and justice, equality and fairness. No author can have thoughts transformed into words, no teacher can make ideas become behaviour and wisdom and art, without those special people who turn our minds to the practical - of getting the job done! Thank you, Robin, Naiyana and Duen for translating those terrible scribbles, called my handwriting, into the still magical legibility of the electronic age. Thank you, Sarah, for your creativity and hard work. My most sincere and heartfelt thanks go to the excellent persons at JP Consulting, and CapStone Academic Publishers. Jessica, you are brilliant, dedicated and caring. Thank you. When Rebecca, Maxwell, Megan Grace, Henry and Felix ask about their Grandad, I will depend on James and Anne, Matthew and Allison, Jessica and Matt, and Benjamin to be understanding and kind. For what I was trying to say and to do was to make my professional life focused on the three C’s - competence, caring, and compassion - and to make my very private personal life dedicated to family - to you all. First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer ix ARE YOU PREPARING FOR EXAMS IN GASTROENTEROLOGY AND HEPATOLOGY? See the full range of examination preparation and review publications from CAPstone on Amazon.com Gastroenterology and Hepatology nd  GI Practice Review, 2 edition (ISBN: 978-1475219951)  Endoscopy and Diagnostic Imaging Part I (ISBN: 978-1477400579)  Endoscopy and Diagnostic Imaging Part II (ISBN: 978-1477400654)  Scientific Basis for Clinical Practice in Gastroenterology and Hepatology (ISBN: 978- 1475226645) General Internal Medicine  Achieving Excellence in the OSCE. Part I. Cardiology to Nephrology (ISBN: 978-1475283037)  Achieving Excellence in the OSCE. Part II. Neurology to Rheumatology (ISBN: 978- 1475276978)  Bits and Bytes for Rounds in Internal Medicine (ISBN: 978-1478295365)  Mastering the Boards and Clinical Examinations. Part I. Cardiology, Endocrinology, Gastroenterology, Hepatology and Nephrology (ISBN: 978-1461024842)  Mastering the Boards and Clinical Examinations. Part II. Neurology to Rheumatology (ISBN: 978-1478392736) First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer x Table of Contents First Principles and the CANMED Objectives ......................................................................... iii Prologue ........................................................................................................................................ vi Dedication .................................................................................................................................... vii Acknowledgements .................................................................................................................... viii Chapter 1: Common Symptoms and Signs in Gastroenterology N. Saloojee ........................ 1 1. Introduction / N.Saloojee, W.G. Thompson and C. Dubé ................................................................ 2 2. Globus / C. Dubé, W.G. Thompson and N. Saloojee ........................................................................ 2 3. Heartburn and Regurgitation / C. Dubé, W.G. Thompson and N. Saloojee .................................... 3 4. Dysphagia / A.S.C. Sekar and N. Saloojee ........................................................................................ 3 5. Odynophagia / N. Saloojee ................................................................................................................. 5 6. Dyspepsia / C. Dubé and N. Saloojee ................................................................................................ 5 7. Nausea and Vomiting / M.C. Champion and N. Saloojee ................................................................ 7 8. Anorexia / M.C. Champion and N. Saloojee ..................................................................................... 9 9. Gas and Bloating / W.G. Thompson and N. Saloojee ....................................................................... 9 10. Constipation / C. Dubé, W.G. Thompson and N. Saloojee ........................................................... 11 11. Diarrhea / W.G. Thompson and N. Saloojee ................................................................................. 13 12. Malnutrition / D.G. Patel ................................................................................................................ 16 13. Acute Abdominal Pain / J.M. Watters and N. Saloojee ............................................................... 17 14. Chronic Abdominal Pain / W.G. Thompson and N. Saloojee ...................................................... 20 18. Abdominal Mass / S. Grégoire and N. Saloojee ........................................................................... 27 19. Proctalgia Fugax / W.G. Thompson and N. Saloojee ................................................................... 29 21. Oral-Cutaneous Manifestations of GI Disease / N. Saloojee ....................................................... 35 22. Extraintestinal changes seen in patients with GI disease ............................................................. 36 Chapter 2: Esophagus W.G. Paterson, S. Mayrand and C.D. Mercer .................................. 45 1. Introduction ....................................................................................................................................... 46 2. Anatomy ............................................................................................................................................ 46 3. Physiology ......................................................................................................................................... 47 4. Symptoms and Signs of Esophageal Diseases ................................................................................ 51 5. Investigations Used in the Diagnosis of Esophageal Disease ........................................................ 53 8. Nonreflux-Induced Esophagitis ....................................................................................................... 64 9. Disorders of the Oropharyngeal Phase of Deglutition .................................................................... 67 11. The Esophagus as a Cause of Angina-Like Chest Pain................................................................ 73 12. Esophageal Neoplasms ................................................................................................................... 75 13. Miscellaneous Disorders of the Esophagus ................................................................................... 78 Chapter 3: Scientific Basis of Gastric Disorders A.B.R. Thomson and R.H. Hunt ............... 83 1. Introduction ....................................................................................................................................... 84 2. Anatomy ............................................................................................................................................ 84 3. Functions of the Stomach ................................................................................................................. 86 4. Hypergastrinemia .............................................................................................................................. 95 First Principles of Gastroenterology and Hepatology A. B. R. Thomson and E. A. Shaffer