DIP Episode 295 - NBME Gastroenterology Series 3 (for all USMLEs)

Okay, welcome. My name is Divine. This is episode 295 of the Divine Intervention Podcast. In this podcast, I'll be continuing the gastroenterology review for the USML exams. Again, as a reminder, if you want to sign up for the Step 2 CG course, it's coming up in about two weeks. It's from the 25th to the 27th of March. It's 16 and a half hours, 5 and a half hours each day. It's from 11 a.m. to 4.30 p.m. Pacific Standard Time each day. So for the reach out to me, again, we'll pretty much cover the different disciplines. Pete, psych, surgery, OB-guine, neurointernal medicine, bio-stats, ethics, and many of those new changes that came up with the health care systems and professionalism, studied in November of 2020. Again, I've had tons of people take the course that I found it to be very beneficial. And then I also have an in-be-me test taking strategy course on the 24th of this month for two and a half hours again. You'll basically teach you how to be an excellent test taker. And again, remember, these two courses are more for people taking Step 2 CG and Step 3. And then from the 5th to the 9th of April, I have a 40-hour Step 1 comprehensive course who go over about 4,000 concepts that pertain to the different disciplines that are routinely tested on the USML Step 1 exam. So again, if you're interested in any of these courses, just shoot me an email through the website.

I'll be happy to point you in the right direction, give you some more information on costs and how to sign up and things of that nature. Okay, let's get right into it. So what if you get a question about a 65-year-old male that I spoke for 80-pack years? Right? Let's say 2 bucks per day for 40 years or I guess 4 bucks per day for 20 years. So, you know, Comzin and says for the last six months, he's been having a lot of trouble swallowing, right? And at first, he'll say that, oh, you know, I had trouble swallowing like they'll give you all these solid foods like nuts, yada yada, yada. But that now, whenever he drinks water, it takes him a long time to feel like it has completely gone down. And let's assume this person has lost like 30 pounds in this time period. If you see this, what should you think about? Well, I really hope you think about this person potentially having a suffigial cancer, right? And remember that, as a joke cancer, again, as I kind of alluded to yesterday, has two major types, right? There's the Squamous Cell type and there's the Adnocarcinoma, right? The Adnocarcinoma is the one that's super common in the US, right? Well, the Squamous Cell type is the one that's actually the most common worldwide, right? So remember, what's the biggest risk factor for a suffiginate nocarcinoma? Your friends at the MBME are very smart. They will give you an answer choice that says, GERD, and they will give you an answer choice that says, Baratisophagus.

If you see both, which one should you pick? I really hope you're telling me that you're going to go with Baratisophagus, right? So you may be like divine. Why is it that it's not GERD? Well, these are, these are your first test-taking strategy. I call these the pathway strategy, right? So you get an MBME question of this sort, for example. We know that you're going to get good first and then GERD is going to lead to Baratisophagus. And then Baratisophagus is going to lead to a Sofajil Adnocarcinoma. So what's the thing that's the closest in the pathway to the problem? It's Baratisophagus. That'll be the right answer, right? That's one thing the MBME does, these days, when they give you a question with, like a bunch of risk factors that you're like, things are pretty similar. Just ask yourself, which one is closest pathophysiologically to the eventual diagnosis? That'll very likely be the right answer, right? So again, remember, Sofajil Adnocarcinoma, that one tends to affect more of, like, the lower third of the Asophagus, right? And again, Baratisophagus is the biggest risk factor. The only reason you should ever pick it as an answer is the biggest risk factor. Is it Baratisophagus is not one of the answers, right? And one thing that your friends at the MBME love to go after, is to measure the lower Asophagus, like this, in terms of, is Sofajil Adnocarcinoma is very can-me-tasticized too, right? So, remember, it likes to go to like the Ciliac-slash-Gastric notes.

Remember the lymph node drainage for the GI tract? Kind of coincides beautifully with the arterial supply, right? So it just makes it a lot easier to remember, actually, right? But again, like I said, if you're thinking more worldwide, we're thinking more in terms of the Sanajil Scrimosel carcinoma, right? And again, like Asophagus, Adnocarcinoma that affects the lower third of the Asophagus, this one affects the upper two-thirds of the Asophagus, right? And again, what are the risk factors here? Again, it's going to be stuff like smoking, right? It's going to be stuff like smoking. Stuff like consuming a lot of like really hot food. Or if the person has a collegia, right? Or if the person has Asophagus, remember in the setting of a promovincencin syndrome, remember those people who have eye-indeciciency andemia, they'll have like a smooth tongue, right? You'll have a lot of side-as. Also, people that try to commit suicide with like consuming like weird stuff, like lie, or adrenal, or bleach, right? Those things, these people essentially set in themselves up for the Asophagus, Scrimosel carcinoma in the future, right? So again, remember, Scrimosel carcinoma is the most common worldwide, but in the US, we're thinking more along the lines of Adnocarcinoma, right? So I think maybe one thing that may be helpful here is giving you a bunch of vignettes on a person that's having trouble swallowing, right? So let me bring up a few here.

So what if they give you a question about someone that, you know, again, this person has tried to, this person tried to commit suicide by consuming lie, so LYE, right, to a bleach, like three months ago, and the person is now having dysphagia. Of course, again, the NBME is smart. They'll put cancer as one of the answers, but it'll be wrong, right? Because again, you're not going to develop a Sofajil Scrimosel cancer within three months of consuming bleach or consuming lie, or anything of that sort. So if you see dysphagia, after a person recently, most of, you know, consumed some kind of caustic substance, you want to think about as Sofajil's structures as the diagnosis, right? The person has developed structures. And other way that your friends at the NBME actually love to test the structures is, they'll give you a question about a person that has like a long history of greed, right? A long history of greed that is, you know, like largely untreated. And then the person has like dysphagia. If you see that again, you want to think about the person potentially having structures. Many times when the body is trying to heal like the lesions, the ulcers and stuff that happens with greed, you can begin to form these fibrosin lesions in the esophagus, and that can cause dysphagia, right? So that's another potential presentation of the Sofajil's structures. And then what if they give you a question about a person that has a history of greed? Has a history of HIV, right?

Or a person that recently had a transplant of some sort? And this person is having dysphagia. What should you think about? Well, I would really, really hope that you're thinking about the lines of Candideles of Ajides, right? Candideles of Ajides. So remember when people have Candideles of Ajides, you want to treat them with a statin, swish and swallow, or you can also use like an isle. You can use like flakonazole. You can use even flakonazole lesanges, right? Like the sweets. You can actually use that. That's actually a bizarre thing that occasionally pops up on MB and yeast, right? So you can use the lesanges form of isles to treat in these circumstances. Right? And again, you know, for those of you that are taking a step on, or if you remember, you'll typically find, you'll typically find like, you know, like white lesions, you know, on the esophageal mucusa. But again, all those things of punched out, laying your ass, blah, blah, blah, blah, blah, blah. They don't really do that anymore, right? Again, that's in every Anki deck. Again, the MB and I people think that these people don't do some kind of research, right? Like they know what met, they know the best ways to test these things, right? These people at least have some kind of awareness, right? Of what's going on out there in the real world. So if you think they don't, you're probably deceiving yourself, right? So just again, just something to be mindful of.

All these buzzwords, the USML is that really not buzzword heavy anymore, right? They're not buzzword heavy anymore, right? But if they wanted to give you a question about a person that has like HSV Sophageitis, they probably give you a person that, you know, has like some kind of immunocompromised. And then many parts of the question will talk about like previous herpes of attacks that the person has had, you know, maybe like cold sores on the oral mucusa, things of that nature, right? So, but again, that's the one that's associated with the punched out lesions, right? Remember for Candida, if you were to take a biopsy, you're going to find a lot of sulohyphy, right? And then the linear ulcers, again, it's going to be in a person that is immunocompromised, super, super immunocompromised like CD4, countless, and 50 kind of deal, right? But again, the thing is to be honest with you on step one, step two, is step three. Whenever they want to test HSV Sophageitis or same V Sophageitis, they almost always are careful to give you the biopsy findings, right? If they don't give you any hints, they just tell you this person has HIV and dysphysia, go with Candida on your exam, right? But if they don't give you anything, if they want you to think of HSV or they want you to think of CMV, they usually will give you biopsy findings. Or they will give you like many antioxidants in the question that tell you that, okay, this person has CMV or HSV Sophageitis, right?

Again, the buzzwords from the past is that, oh, in CMV people have like linear ulcers, but in HSV Sophageitis, those people have more, you know, punched out, more punched out lesions. Again, just things to keep in mind. And obviously, if it's HSV Sophageitis, you're going to give those people a cyclover. If it's CMV Sophageitis, you're going to give GAN cyclover. Right? Remember, if GAN cyclover doesn't work, then you'd have to proceed with false carnage. Right? Although, please, please, please, please, please, please, please, do not forget that if GA Ns, the mechanism of resistance to GAN cyclover, right? Your friends at the immediate love to test this. Remember, GA Ns cyclover, those distinct where you need to activate it with a UL97 kinase for it to become active, right? To work in the patient. So if for some, you know, bizarre, for sure, bizarre unfortunate reason, the person has a UL97 kinase mutation, right? The CMV like develops that mutation. Then suddenly, in those circumstances, what you would, unfortunately, what you need to do is you would need to, how do I put this? You would need to give the person a false carnage, right? Because false carnage does not require any kind of activation. You can remember, false carnage is a, is a pyrophosphita and a lach. Okay. Now, what if they give you a question about a person that's from South America? And for the past six months, the person has been having a lot of dysphysia. If you see that, what should you be thinking about?

Like a person from Brazil or whatever. Although my geography is not very solid, sadly. I'll hope you think about ecalysia, right? And what's the thing that's potentially causing this person's ecalysia? I'll hope you're telling me it's tripanosomer-curzii, right? Tripanosomer-curzii, right? So remember, people that have ecalysia, right? They are lower social factors. They cannot relax it appropriately, right? And typically for these people, the first thing you do is you get a barium swallow, right? And when you get that barium swallow, you'll typically find that they will have this bird's beak sign, right? They'll find this bird's beak sign that's like a distal teaprin of the lower softwares, right? And then after you do the barium swallow, the second step in diagnosis usually will be some kind of esophageoma nonmetry. And you'll notice that on the esophageoma nonmetry, they will actually have like abnormal peristosis, right? You'll have decreased peristosis, so you can use the term e peristosis of the midasophagus, right? That's a pretty classic finding ecalysia. But the thing is, you can say, well, I've seen the bird's beak, I've done the monomotry, okay? Done. No, no. You can stop there, right? Your third step is you'll do an operating doscopy, right? Again, remember, that's what's called an eGD, or I guess you won the four term. It's so far go gastro-dwanoscopy.

It's basically a colonoscopy, but instead of looking at the colon, you're going from up high from the mouth, and you're looking at the esophagus, the stomach and the duodenum, at least the early parts of the duoden, right? Because again, sometimes what may be bird's beak on biomeswallow is actually a severe geoch cancer, right? So you usually have to do some kind of eGD to elicit the diagnosis. So maybe like, okay, divine, what's the pathophysiology here? Well, the pathophysiology here is basically you don't have ganglion cells, right? In your alboxplexes. Remember, alboxplexes is also found in the esophagus as well, right? So these people have like very increased lures of a geospinter tone, right? Comparatively, it's like a disease like scleroderma, right? Where people that have scleroderma, they tend to have like decreased lures of a geospinter tone, right? Again, that's a subtle difference, but it's very high eothenopherexams. So people that have ecalysia, they have increased lures of a geospinter tone. People that have scleroderma, they have decreased lures of a geospinter tone, right? And then, remember that, you know, if a person has ecalysia, there's many different things you can do for treatment. You can inject the Botox stocks in, right? To paralyze those muscles, right? To reduce that tone. I mean, that is unfortunately, it needs to be like sick kid that roughly every six months.

Another thing you can do is you can do a pneumatic dilation, although that's usually not done anymore because it causes a lot of problems. In fact, there's a classic NVME question that you love to test on this, where you tell you that a person just got pneumatic dilation for ecalysia, right? And then, a few hours later, the person is like crashing and burning, super hypotensive, super febriol. And then, you notice that the person has subcutaneous and fizima, right? To remember, those people, they have perforated their esophagus. If perforated their esophagus, in those circumstances, it's usually the smart thing to do to make the diagnosis that, oh, if perforated their esophagus, is to do some kind of gastrographine study, right? It's a kind of radiological study. You put down gastrographine, and you'll see going into the presence of a mediasitinum kind of like sipping in there. Sometimes they call this gastrographine water solubol contrast enema. Again, classic NVME question there. Don't give barium. If you suspect that a person has perforated their esophagus, you don't want to do a barium study, right? Because if the barium gets into the mediasitinum, you're going to have a whole new set of problems, right? Barium and the mediasitinum, they are not very good friends. They don't do very well together, right? So again, in Malaysia, again, ultimately, you can also do surgical therapy. That's probably the best thing to do to relieve the person's symptoms.

Okay, what if they give you a question about a patient, you know, 62-year-old male and the tell you that on physical exam, he has like flapping of his hands, right? And he has like a fluid wave on abdominal exam that's shifting. And then the tell you that he presents to the emergency room, which like really bad hematemesis that begins suddenly. If you see that, what should you be thinking about? What would really, really hope you're thinking about a person having esophageal viruses, right? Esophageal viruses, remember, this person is an alcoholic. The flapping of the hands I'm talking about is essentially this person having asterisksis, right? Esophageal viruses are a severe disease, so why that happened? Well, the drunken ton, the liver goes by by, right? The liver is no work in. You're going to have increased portal pressures. This is going to translate all the way to the esophageal miocoses, especially those sub-miocosal vessels, right? That line their softagas, right? So the pressures are too high, those vessels kind of explode. When you explode, you're going to cough a blood, basically, right? That's the esophageal viruses. So, the pressing has esophageal viruses, well, what do you do for them? Well, some things you can do for them on MBM exams, right? You can do like bonding, you can do sclerotherapy, those all things you can do. And typically, one thing you're doing the acute fees as well, is you give IV Octriotide.

Basically, IV Octriotide lowers the person's portal pressures, so it can help. And then, typically, especially for step 2, CK step 3, you usually want to give those people some kind of antibiotic prophylaxis. It's usually like an IV fluoroquinolone, right? It kind of reduces the risk of them having like some kind of spontaneous bacterial pair tonight, is. But let's say you've tried all these things, right? And obviously, you're going to give them fluids, whenever a person has a GI bleed of any sort, it doesn't matter what's causing it. Your first step is always to insert an IV, that's a classic searcher's shelf question, or you know, medicine's shelf question, or step 2, CK step 3 question. Insert an IV, give them blood, give them fluids. That's always the first thing to do. And usually, you give the fluids first before you give the blood. That's always what you do first before you start doing this band-in-slur therapy business. Well, at least you've tried all these things for Ecclesia. I mean, for a sort of a geovarious season, it's not working. Well, what are you going to do for these patients? Well, one thing you can do for them is you can go ahead and give them a... You can call interventional radiology, and they will do this thing called a tips procedure, right? Again, something that you can even test on step 1, remember, tips means trans hepatic... ...interest something, porosystemica, shunt.

You basically make a conduit that connects the poroving to the hepatic vein, so you pretty much bypass the liver. So what's the potential complication with that procedure? Well, the thing is, you're basically bypassing the place where the urea cycle happens. If you bypass the place where the urea cycle happens, well, your ammonia is going to go up, right? And if your ammonia goes up, the person can have ultra-bental status as a result of that, right? They can develop hyperamonini, right? So one very unique NV Me question can be, oh, in addition to performing a tips procedure, what's your next best step? You want to give the person as much lactose as you can, right? Remember, the lactose is converted to lactic acid in the GI tract, right? And then, you know, you can acidify the ammonia, so they can poop it out, so that it doesn't cause, it doesn't go to the brain and cause ammonia problems. You can also give those people a faxing in as well, right? So again, this is just all things you should do. So always, always, always be aware of the hyperamonemia in a person that has a SOGO varicese. And I have some drugs you can give on NV Me exams to profile acts, basically like to reduce a person's risk of having bleeding episodes. If you know they have SOGO varicese, the answer to that question is yes, right? So you can give a bit of blocker, right? You can give per perinolol. You can give per perinolol. You can even give an outdo-strand receptor antagonist like Spirano lactone.

The buzz word that you only remember there is that these things cause splanchonic viso-constriction. Again, I can go into like deep, deep pathophysiology here, but it's probably beyond the scope of our discussion. But let me just give you some hints. Basically, splanchonic viso-constriction means you are doing some magic to pharmacologically to prevent blood from going to the poreo vein. If you prevent blood from going to the poreo vein, then all those veins that feed the poreo vein will begin to enjoy those lower pressures because it's almost like they have like breathing room of some sort, right? They have some breathing room of some sort. So just something to keep at the back of your mind for for exams. Now, what if they give you a question about a student, you know, you know, it was recently accepted to med school. He just found out a few hours ago and then, you know, he went drunk a ton and then now he presents to the hospital. He has like painful hematemesis. Well, other than the painful hematemesis, he literally has nothing else. His blood pressure is fine, heart rate is fine, all those things. If you see that, right, you want to think of a malaria-wise tear, right? Well, think about a malaria-wise tear. Remember, when people have malaria-wise tears, it's literally limited to just the esophageoma eucosa, right? And then what if they give you a question about a cheerleader? You know, she has a BMI of like 14 and she presents with like very painful hematemesis.

Temperature is like 105 degrees Fahrenheit, so obviously really high, right? And then again, you see so cutaneous infosima. And then you even tell you that, oh, they perform a chest X-ray. And you see like gas bubbles tracking amongst the walls of the trachea, along the walls of the medius stina, right? Or around the lymph nodes of the medius stina. If you see that, I'd really hope you're thinking about behalf syndrome, right? Bair has syndrome. Remember, this person, you know, BMI of 14 very likely has anorexia, right? Rechin, rechin, rechin, big time, right? Well, we didn't have a ton, right? So this person has a behalf syndrome. And that's not a mecosaltier, like what we have in my lawyer's wife, right? This is a transmural tier, right? And again, you know, these people tend to have like this rise, grace, peace, sensation, right? Because they have this subcutaneous infosima. And again, they will have no more medius stina on imaging. And again, basically these people need surgery like yesterday, right? They need surgical therapy, like very, very quickly. Sometimes they may say that you need like a ciliotomy, C-E-L-I-O-T-O-M-Y, on MBMI exam. Ciliotomy is just something that's used to describe procedures that involve, you know, like the softwae gas where you need to make like an open incision and fence, fence of that sort, right? And these people need a ton of antibiotics, right? Especially like some kind of third generation cephalosporine like ciftraaxal, for example.

Although usually when people are going for surgery, this is actually a healthcare systems question that pops up on the USMELIS. When people are going for surgery, and you need to do antibiotic prophylaxis, you're looking along the lines of a cephalazole. Remember, that's the first generation cephalosporine. Again, I want to keep these podcasts short, so I'm going to go ahead and stop here. Again, please subscribe to the podcast. If you want to get like an email notification whenever I make a new podcast, just go to the podcast website at evanintervationpodcast.com with an S at the end, and you know, go ahead and subscribe. And then I have this podcast, an Apple podcast, a Google podcast on Spotify. So go ahead and go ahead and you know, should subscribe. And again, any feedback or help, definitely helps. And then I have my videos, super, super high-yield videos on my You Tube channel, Devine Intervention, USMELIS podcast and videos. And then I also offer one on one, tiering for all the USMELIS exams, 30-ish off exams, prickling gourmet school exams. And I want to also tutor like medicine residents for the intern medicine boards and the internals medicine training exams. So if you're interested in any of these things, just shoot me an email through the website. And again, I'll be able to give you some more information on cost, payment, structure, and how I can construct my sessions. So thank you for listening. Have a wonderful rest of your day. God bless you.

See you next time.

Adenocarcinoma, which typically affects the lower third of the esophagus.

Barrett's Esophagus (which develops secondary to chronic GERD).

Strictures (due to scarring/fibrosis).

The "bird's beak" sign at the gastroesophageal junction.

Somatostatin analogs (e.g., Octreotide) or alpha-agonists.

HSV typically shows punched out lesions; CMV typically shows linear ulcers.

Barium entering the mediastinum (which is dangerous). Instead, use contrast enemas or specialized imaging.

Squamous Cell Carcinoma (SCC); affects the upper two-thirds of the esophagus.

Smoking, hot food consumption, lye ingestion, or conditions like Plummer-Vinson syndrome.

Loss of ganglion cells in the myenteric plexus, leading to failure of LES relaxation and increased tone.

Foscarnine (or Cidofovir).

Dysphagia + Barium swallow "bird's beak" sign + Manometry showing aperistalsis/high LES pressure.

Subcutaneous emphysema and pneumomediastinum (gas tracking in the mediastinum).

It is metabolized to lactic acid, which acidifies ammonia ($\text{NH}_3$), allowing it to be excreted via the GI tract.

Squamous Cell Carcinoma (SCC); affects the upper two-thirds of the esophagus.

Smoking, hot food consumption, lye ingestion, or conditions like Plummer-Vinson syndrome.

Loss of ganglion cells in the myenteric plexus, leading to failure of LES relaxation and increased tone.

Foscarnine (or Cidofovir).

Dysphagia + Barium swallow "bird's beak" sign + Manometry showing aperistalsis/high LES pressure.

Subcutaneous emphysema and pneumomediastinum (gas tracking in the mediastinum).

It is metabolized to lactic acid, which acidifies ammonia ($\text{NH}_3$), allowing it to be excreted via the GI tract.