Location:
Outpatient: Univeristy Gastroenterology, MOB B, Suite 100 and
Thomas Young, MD, MOB B, Suite 105
Inpatient: UTMCK, various floors, Endoscopy Lab
Faculty:
Carlos Rollhauser, MD, Chief, Division of Gastroenterology
Mark D. Anderson, MD
Sandy Gulati, MD
Ramanujan Samavedy, MD
John A. Stancher, MD
Thomas Young, MD
Schedule: Days:
7:00 AM to 6:00 PM
The resident should complete inpatient work rounds then meet with
their assigned attending for management rounds at 8 AM . The resident
will follow the schedule of the assigned attending with approximately
one half of each day spent seeing patients in the office and the
other half performing the initial consultation or subsequent care
for selected inpatients and in the endoscopy lab. The resident is
expected to attend all Noon Conferences, Journal Club and Grand
Rounds while on the rotation
Multidisciplinary
GI Conference, 2nd Monday, 7:00 – 8:00 AM , Morrison’s
Conference Room
Primary Goals:
Gastroenterology encompasses
the evaluation and treatment of patients with disorders of the gastrointestinal
tract, biliary tract and liver. Residents are expected to learn
a broad overview of the pathophysiology, diagnosis, and treatment
of common digestive diseases through a practical program of working
directly with patients, reading broadly and specifically from medical
textbooks and current journals, writing appropriate consults and
presenting clinical cases. The general internist should be able
to evaluate a broad array of gastrointestinal symptoms and manage
many gastrointestinal disorders. Although the general internist
is not expected to perform most technical procedures, he or she
must be familiar with the indications, contraindications, interpretation
and complications of these procedures.
Primary Objectives:
A. Residents should be able to perform a thorough gastrointestinal
history and physical exam and understand the clinical significance
of the findings. The attending physician will review history and
physical examination findings on both ambulatory and hospitalized
patients.
1. To understand
the significance of abnormal findings noted in the clinical
history and review of systems including heartburn, dysphagia,
chest pain of esophageal origin, abdominal distension, abdominal
pain, nausea and vomiting, food intolerance, diarrhea, jaundice,
constipation, fecal incontinence, weight loss, blood loss, and
complaints of gas.
2. To
accurately evaluate the abdomen by physical examination and
to interpret the abnormal appearance and findings involving
the liver, spleen, masses, hernias, bowel sounds, bruits, tenderness,
signs of peritoneal inflammation, ascites, anal and perianal
lesions, rectal lesions, and abnormalities of the oral cavity.
3. To
identify systemic signs of chronic liver disease, including
jaundice, parotid
enlargement, spider
angiomata, palmar erythema, alterations in secondary hair
characteristics,
gynecomastia, testicular atrophy, Dupuytren’s contractures,
caput
medusae, hepatic
encephalopathy, esophageal and rectal varices, and hemorrhoids.
4. To
identify signs and symptoms of gastrointestinal bleeding, including:
hematemesis, melena, hematochezia and occult blood in the stool.
5. To
recognize clinical signs of malnutrition and specific signs
of nutritional deficiencies and initiate treatment.
6. To
be familiar with the fundamental diagnostic approach to the
gastrointestinal manifestations of immunodeficiency disorders
and common gastrointestinal problems in the pregnant patient.
B. The resident should understand the methodology and clinical significance
of tests that provide diagnostic information about the liver, pancreas
and gastrointestinal tract including:
1. Abnormal liver function
tests.
2. Tests
of acute and chronic hepatitis including viral serologic markers,
antimitochrondrial antibody, anti-smooth muscle antibody, anti-nuclear
antibody, alpha 1 antitrypsin level, ceruloplasmin, serum iron
and total iron binding capacity, carcino-embryonic antigen and
alpha-fetoprotein.
3. Tests
of pancreatic function, including serum amylase and lipase,
bentiromide test, qualitative fecal fat examination, and secretin
test.
4. Tests
of maldigestion and malabsorption including the qualitative
fecal fat stain of the stool for free and split fats, serum
carotene, prothrombin time, quantitative fecal fat analysis,
and xylose absorption test.
5. Tests
for both acute and chronic diarrhea including stool volume,
response to fasting, osmolarity and electrolyte content, fecal
leukocytes, stool culture, stool examination for ova and parasites,
and stool examination for clostridium difficile toxin.
6. Tests
of gastric function including serum gastrin, pentagastrin stimulation
for gastric analysis, and secretin provocation for detection
of gastrinoma.
7. The
interpretation, indications, and complications of radiologic
examinations of the liver and gastrointestinal tract including
upper GI series, barium swallow, small bowel follow through,
barium enema, abdominal ultrasound, abdominal CAT scan, HIDA
scan, labeled red cell scan, and abdominal angiography.
8. The
indications and complications of gastrointestinal tract endoscopy
for both therapeutic and diagnostic purposes including upper
endoscopy, colonoscopy, enteroscopy, capsule endoscopy, ERCP,
variceal sclerotherapy, variceal banding, polypectomy, coagulation
of gastrointestinal hemorrhage, endoscopic sphincterotomy, biliary
stent placement, and dilation of strictures in the esophagus
and elsewhere in the GI tract.
9. The
indications and methodology for evaluation of esophageal disease
including esophageal manometry and 24 hour pH monitoring.
10.
The indications for paracentesis and liver biopsy, and the complications
associated with
those procedures.
C. The resident should be able to establish
a professional relationship with the patient, be sensitive to the
anxieties of the patient and their family, and be able to effectively
communicate with the patient and their family about the disease,
the anticipated diagnostic evaluation, and therapeutic intervention.
This core competency will be a point of focus by the gastroenterology
service.
D. The resident should be familiar with
the cost of daily hospital care, specific diagnostic tests and therapeutic
interventions and should be able to compare sensitivity and specificity
of the tests and relative value of the various therapeutic alternatives.
E. The resident should be familiar with
the pharmacology, indications, side effects, and costs of commonly
prescribed gastrointestinal medications including histamine 2 receptor
blockers, proton pump inhibitors, sucralfate, metoclopramide, mesalamine,
steroids and immunosuppressive agents such as infliximab, etc.
F. The resident should
be familiar with how to use library resources and computer literature
searches to answer specific questions related to patient care.
G. Consultations:
The resident will be asked to present a
concise but thorough history and physical exam with special focus
on the gastrointestinal symptoms. Major emphasis should be placed
on the assessment including the differential diagnosis, the specific
points in the case which were in favor of individual items in the
differential diagnosis and the suggestions for further evaluation
and management. After discussion with the attending physician and
review of the literature, recommendations will be made. For all
consults, it is imperative that the GI consultation team communicate
in a direct verbal manner with the consulting physicians to be certain
that their questions have been answered satisfactorily and to facilitate
carrying out the additional diagnostic and therapeutic procedures
suggested.
Braunwald, E, Fauci,
AS, Kasper, DL, Hauser, SL, Longo, DL, and Jameson, JL (Editors)
Harrison’s Principles of Internal Medicine,
15 th Edition. 2001. New York : McGraw-Hill. RC46.H32 2001 (
Preston )
Rose, BD (Ed); Up-To-Date,
Wellesley , MA , 2004. Specific topic areas to be provided at
a later date. Available in Preston Medical Library.
Additionally, a database
of recent review articles and important publications is available
in the office in PDF with articles selected from leading medical
journals.
9. Procedures: The
resident will be expected to perform nasogastric intubation and
abdominal paracentesis under supervision. The ACGME encourages residents
to become proficient in limited colonoscopy. The resident will observe
full colonoscopy, upper endoscopy and hepatic biopsy.
Interested residents are encouraged to
discuss ongoing clinical trials with the faculty. The faculty is
available to assist the resident with preparation of case reports
or poster presentations on selected patients.
12. Method of Resident
Evaluation:
Each resident is informally and continually
evaluated during the course of the rotation on the basis of history
taking and physical examination skills, written notes, case presentation
and discussion and general participation in the activities of the
service. The resident will be asked to demonstrate understanding
of common and important concepts in gastroenterology by the end
of the rotation. A summative evaluation form will be completed by
the supervising attending via New Innovations at the end of the
rotation and direct verbal feedback will be given.
13. Method of Specialty
Evaluation:
Residents are asked to provide feedback
to the attending in an informal manner during the course of the
rotation. They will complete an evaluation form using New Innovations
at the end of the rotation. Cumulative feedback to the attending
faculty member will be given by the Departmental Chair as an annual
review.
