DIP Episode 298 - NBME Gastroenterology Series 4 (for all USMLEs)

Okay, welcome. My name is Divine. This is episode 298 of the Divine Intervention Podcast. And in this podcast, I'll be continuing our gastroenterology review series for the USML exams. Again, after all you said and done, this should be pretty comprehensive. So I've done three parts. So this is part four. Okay, so let's just jump right into it. So what if they give you a question about a 50 year old guy? Any presents with thisphasia? And they tell you that oh, they perform in dark scopy and it reveals like a circle of well-demarcated tissue at the squamous columnar junction of the esophagus. What should you be thinking about there? If I have some things, they can tell you that oh, this guy has like intermittent dysphasia. What should you think about? I would really hope you're thinking about something called Shatsuke's ring. Right? Shatsuke's ring. So the thing is, for whatever bizarre reason, lots of med students have really struggled with identifying a Shatsuke's ring on an empty mixer. So the thing is there's some key details, some key pieces of information that I'll tell you. Oh, yeah, this is Shatsuke's ring. This is nothing else. Right? So the thing is they will tell you that the person has intermittent dysphasia. And of course, that's handy many of the things, right? But they will usually give you EGD results. Right? So like results of an esophagus gastro-dodinoscopy. Right?

So all those EG Ds usually tell you, well, those EG Ds will tell you that oh, there is a circle of tissue. Right? Around the squamous columnar junction. I mean, there are many different kinds of Shatsuke's ring, but that's beyond the scope of our discussion right now. So some of you may be like, okay, divine. How do I differentiate that from Plumber Vincent? The thing is, Plumber Vincent, they have like extra tissue that's, you know, kind of lining the wall of the esophagus, but it doesn't make a complete circle around it. That's how you differentiate a Shatsuke's ring from Plumber Vincent. Plumber Vincent is the the extra tissue does not like the esophageal web essentially does not completely encircle the esophageal mucosa. Right? What Shatsuke's ring it does. Right? And again, Shatsuke's ring, it's basically like extra esophageal mucosa with one extra muscle. Right? That again can cause like a partial or a complete obstruction of the esophagus. Right? And usually if you want to meet the diagnosis, you typically would do like, you know, when the person presents with this facial, it's usually a smart idea first to do some kind of barium swallow. Right? You can actually diagnose a Shatsuke's ring with a barium swallow, but you know, you don't stop there. The thing you usually do after that is to make sure that you perform an EGD. Right? Again, that will help you confirm the diagnosis. Just make sure again that there's nothing weird going on like cancer, for example. Right?

So for the most part, many people that have Shatsuke's ring, they actually seem to medicate. It's actually a relatively common condition in the population, believe it or not. So for these people, for the most part, you don't do anything for them. Right? But when it becomes symptomatic, right? Like many times people tend to do this of a geodialition. Right? They tend to do this of a geodialition, although remember when a very diluted presence is of this, they're also taking like the time-honored risk of preferring the presence of a syphagus. Right? And if you preferring the presence of a syphagus, the something that could happen is, you know, they'll have like stuff from the outside or going to the medius dynum. And they can get into a lot of trouble pretty quickly. And remember whenever you've prepped the presence of a syphagus, usually the smart play, if you're trying to meet the diagnosis is, don't do barium swallow. Remember, barium is very bad for the medius dynum. So if you think that a person potentially has a connection between the syphagus and the medius dynum, then don't use barium. Use water solubil contrast. Right? Sometimes the colleague gastrograph in NMA. Right? So I know I just mentioned that, oh, you know, if you see a person that has dysphysia, they could also have ploma vencin syndrome. Well, remember, ploma vencin syndrome is essentially a triathlete. Right? These people have iron deficiency and emia. They'll have esophageal webs.

Remember esophageal webs are almost like a shatsky's rank. But the big difference is that that extrême ecosol tissue does not make a complete circle around the syphagus. Right? And they remember these people also have like tongue problems. Right? They can have like a beefy red tongue or whatever. Right? Just kind of watch out for that. So again, your friends at the NBME, if you're not going to say, oh, a patient presents with iron deficiency and emia. It's a phageal webs and a beefy red tongue. No, that's ridiculous. Right? And I'm going to do that on an exam. Right? So the thing they're going to do is they're going to talk about some patient, you know, can be like an old female. You know, she presents with dysphagia. And then they can tell you that all CBC with differential, you know, they give you all these labs. And you notice that while this person's ferritin is low, this person's transferring is high. This person's transferring saturation is low. Right? And the person has a high free ethoside proprfate. Right? If you see all those things, right? You see like anemia in the setting of dysphagia. Then you really want to think about, especially like a micrositic anemia in the setting of dysphagia. Then you want to think about a plumber of insulin syndrome. Right? So let's explain some of those iron labs. Right? I don't want to be giving you facts with no context. Right? So remember, if a person has iron deficiency and emia, they are literally deficient in iron.

If you're literally deficient in iron, think about it. It's going to be really hard for you to have much of any iron stores. Right? I remember your iron stores are represented by ferritin. So ferritin is going to be low. Right? Now, if your ferritin is low, then your TIBC is going to be high. Right? Remember, TIBC stands for total iron binding capacity. Right? You're literally like if you notice that you're deficient in something. Right? So let's say you notice that, you know, God forbid, there's little money in the home. Well, you know that, okay, I need to go out and bind some money by working. If I need to flip burgers or whatever, I'll do that to get some money. Right? So the thing that happens is, if ferritin is low, everybody will be like, okay, dude, go out. It sends transferring out. Go and bind iron as much as you can. So your TIBC will go up. Right? But again, remember, you're deficient in iron. Right? So that transferring that you have going to scavenge iron is not going to be saturated with iron. Right? So your transfer in saturation is going to be low. Now, the part about the high-freory throside protopuffering. Well, again, that should make sense. Remember, for you to make him, he is like the union from iron and protopuffering coming together. Right? Iron and protopuffering, they come together and they get married and then they form here. Right? So the thing is, remember, for a marriage to happen, both people need to show up. Right?

You can just have one person showing up and the other not showing up. If one person does not show up, then the other person will start building up, getting pissed off and all that stuff. Right? So essentially, if protopuffering is showing up, but iron is not showing up, that protopuffering is going to keep building up. Right? So the free-rethrocyte protopuffering increases in a person that has iron deficiency andemia. Now, what if they give you a question about like 55-year-old male, they tell you that, you know, he presents with dysphysia, and they tell you that, oh, he has these episodes where he vomits or regurgitates the same food that he eats last like the previous day. And then they tell you that, oh, he's, he came into the clinic today because his wife has been saying that his breath smells really bad. Right? The buzzword they'll use on an in-bim exam for that, like for bad breath is a halitosis, H-A-L-I-T-O-S-I-S. Right? Halitosis. That's like the 50 word for bad breath. Right? So, you know, if you see stuff like this, I really hope you're thinking about Zenker's diverticulum. Right? I hope you're thinking about Zenker's diverticulum. Right? So, remember, Zenker's diverticulum is a diverticulum you have in the upper third of the esophagus. Right? If you have a diverticulum in the middle third of the esophagus, that's a traction diverticulum. Right? And then if you have a diverticulum in the lower third of the esophagus, that's an epiphranic diverticulum. Right?

And people may be like, oh, divine, how do I remember what is in the upper third, what is in the middle third, what is in the lower third? Well, let me give you a trick. The trick is to remember the telephone company ZTE. Right? So, upper middle lower third ZTE. Z for Zenker's, T for traction, E for epiphranic. Right? That's a very nice way to keep that straight. Right? So, Zenker's diverticulum, remember again, it's actually a false diverticulum. Right? It's actually a false diverticulum. Contrast this with mechols diverticulum. Remember, that one is more in the... That one is more in the right lower quadrant. Excuse me there. Right? So, that one is in the right lower quadrant. That's actually a true diverticulum. Right? So, it includes all the layers of the geniacosa. You know, macosa, submucosa, and the muscularis, external. Right? But Zenker's is a false diverticulum. Right? So, basically, it's like the mechosa and the submucosa alone that I involved. That's very high, you know. It's just the mechosa and the submucosa alone that I involved. Right? So, the mechosa, submucosa, and the junction, right, between like the suffocates and the farings, the herniets through weakness in a muscle. Right? This muscle is the crack of iron gel muscle. Sometimes people call it the crack of iron gel muscle. Right? And this, so in the crack of iron gel muscle, there's a point of weakness. That weakness point is commonly known as killions, like, you know, kill and then IEN, kill and EN.

Right? So, kill and EN, KiWL, IEN, triangle. Right? So, again, that Zenker's diverticulum. And again, how do you diagnose this stuff? You're going to go ahead and do some kind of barium swallow. Right? You're going to see the diverticulum. I'm going to do the barium swallow and see the diverticulum. Your next step is to do a diverticulaectomy. You go ahead and chopouts the diverticulum and obviously repair the esophageal your cosa. Now, they will try to trick you into doing an EGD. This is actually one of those GI disorders where you don't do that as so for gold, gas, throw the water and ask for it. Because again, literally think about it. It's literally a point of weakness in the wall. Do you think it's a smart idea to start bringing a scope through that? What if the scope caught through that? Right? And then the person essentially prefer it's the diverticulum. That's going to be a huge problem. Right? So, typically, your name being exempts, do not select EGD as a trend of diagnostic test. You would want to employ in a person with Zenker's diverticulum. In fact, they can give you a question about a person that has Zenker's and they did an EGD. And then the person has ultra-demental status, really high fevers, powerful locus eye toces and all that badness. If you see stuff like that, that's essentially them telling you that the suffocates were preferring it in that procedure. Right?

Now, what did they give you a question about, like, a 45-year-old guy and they tell you that he has this chronic ongoing history of like really, really bad abdomen-open 2-3 hours after every meal. And his BMI is 31. Right? So you see this person, the abdomen-open seems to come a long time after the person is eating, you know, like 2-3 hours after the meal. If you see stuff like this, I would really, really hope that you're thinking about a Diodenal ulcer. Right? I really hope you're thinking about a Diodenal ulcer. Right? So what's the pathophysiology here? Well, remember, whenever you eat your Diodenum, remember your Diodenum has these brunner glands. So they're like, oh, okay, let's make bees so that we can deal with this acid problem from the food coming from the stomach. Right? But, and whenever you make that base, right? Remember, base is very good for soothing ulcers, right? So, you know, right after these people eat, you know, they're making a ton of base. So it's soothing the ulcers. So the ulcer doesn't feel as bad. Right? Well, like 2-3 hours after, you know, meal, all the stomach, all the food has gone through the stomach. So those brunner glands are like, okay, we don't need to make bees anymore. And then guess what? That ulcer becomes exposed again. It starts hurting. So guess what? Because these people know that whenever they eat, they make bees ulcer symptoms reduce. They eat a ton.

So these are people that will tend to have like a big BMI, like this person has a BMI of 31. This person is clearly in the obese category. Right? So this person has a Diodenal ulcer. Right? So what's the most common cause of Diodenal ulcers? About 90% of them are caused by H by lorry. Right? That's very high, you know, the biggest risk factor is very high. The biggest risk factor for Diodenal ulcer on MMI exams is H by lorry infection. Right? Now, one thing that can happen with Diodenal ulcers that I think is very high, you know, is what if they give you a question about a person that has a Diodenal ulcer? And then they tell you that, oh, the person suddenly starts having like him up to say, right, bloody bowel movements, person becomes super hypotensive, person bleeds out and dies. Right? And then they can say, what is the most likely finding on autopsy? Or they can even ask you like, what's the most likely mechanism behind the presence of symptoms? I want you to think about the person having the ulcer erode all the way down to the gastroid one or other. Right? Erode in all the way down to the gastroid one or other. What do I mean by that? Then again, maybe like, man, this is super weird. It's super weird, but it's super high, you know, for example, I'll say that again, it's super weird, but it's super high, you know, for MMI exams.

And to be honest with you, it's actually pretty high yield for people that are going into gastroenterology and people that are going into general surgery. Right? This is something that actually does happen to be honest with you. I'm almost certain I've seen this clinically, like right before my eyes. Right? This thing is an absolute nightmare. Right? When people start bleeding like this, it's usually like pretty bad. Right? And you know, the die. Right? This thing is actually like it can actually kill. Right? Believe it. So this like relatively early in my time as a physician. Right? So why is it a gastroid organolary problem? Well, the thing is if you have a organololus, remember the gastroid organol auto supplies the, supplies the ultimately, let's say like the greater curvature of the stomach. Right? So because it supplies the greater curvature of the stomach, right? It also actually, you know, supplies some parts of the, of the blood. Right? So the thing that can happen is if you have an also that erodes, remember? And also, right? Kind of starts in the Mucosa surface, but if you keep seeroding, Mucosa, all the way to the sub-Mucosa, it impacts those blood vessels. Well, the thing is you can, those blood vessels can blow out. Right? And then the person can bleed. And these bleeds are very life threatening. I'm telling you, these bleeds, they are very life threatening.

If you see them in the, in the real world, like a pressing bleeding from the GDA, from the gastroid organolary, is one of those things you can never really forget. It's pretty sodding, but it's pretty grotesque when it happens, like blood coming out from the presence mouth in droves. Right? Just something you want to be aware of for, for example, right? And also clinically. Right? So make sure you know that association with the organolus, right? That's something that your friends at the MbMe love to test. But I guess since I'm talking about the gastroid organolary, what's another weird thing your friends at the MbMe love to throwing with a gastroid organolary? It's actually this whole concept of people having like gastroid organolim, hematomas after starting like an anticoagulant. Right? So they will give you a question about a person that, you know, maybe the person has like some disease, you know, like, I don't know, like a fable, whatever, where they need to be placed on some kind of anticoagulation, you know, long term. And then they tell you that, you know, after the person was started on this anticoagulant, like, warframe, heparin, whatever, the person starts complaining of this non-specific abdominal pain. And then sometimes they can be nice and see, oh, the person is having him up to his bloody bowel movements.

But many times the smart thing that they do, you know, being your friends at the MbMe is they will give you that the person's hemoglobin has been dropping over time. Right? So they will tell you that, oh, you know, when the warframe was started, the person's hemoglobin was like 13 grams per deciliter. Right? And then you notice that, man, it's like two weeks later, this person's hemoglobin is like six grams per deciliter. And the person is having like abdominal pain. If you see that, I really, really want you to think about some kind of abdominal hematoma, right? Like a gastroid abdominal artery hematoma. Right? Again, it's one of those high yield things you need to keep at the back of your mind. It has that temporal association on MbMe exams, with a person, with a person recently started on anti-couagulanta therapy. Right? And remember that also initiating an anti-couagulant, right? You can cause hematomas in all those structures, right? So what are these other hematomas that your friends at the MbMe love to go after? They love to love to go after these rectus sheath hematomas, right? Rectus sheath hematoma is absolutely something that you could see on an MbMe exam in a person that has that, you know, again, just recently started taking some kind of anti-couagulation. Another thing you bet for this on an MbMe is these people, they may tell you that a person was just recently started on some kind of anti-couagulation.

And then you notice that, man, these people are having like subtle anesthesia, right? They're having like low back pain, things of that nature. If you see things like that, I really want you to think about a spinal epidural hematoma, right? Many people think that for some reason, the only place you can have epidural hematomas is in the brain. That is not true. Right? Remember, you literally have those three-minute joke offerings also in the spinal cord as well, right? One common complication of initiating anti-couagulation therapy on MbMe exams, especially when you see like back pain and neuro deficits, is a spinal epidural hematoma. Again, I know some of these things are not GI, but they are floridly high-yield to know for your USML exams. So as they come up in my mind, I just figure it will make sense to go ahead and talk about them. Okay. Now, what if they give you a question about a 30-year-old female, you know, they tell you that she presents with a one-year history of like, you know, like chronic diarrhea, polydipsia, polyurea, right? And then, over the last year, they say, oh, you know, she has noticed that her heart, her shoes, her rings, they don't fit, right? And then they tell you that, oh, her friends notice that, man, she looks really different from the person they knew like a long time ago. If you see stuff like this, what should you be thinking about? I really hope that you're seeing that, you know, this person potentially has MEN1 syndrome, right?

First of all, it potentially has MEN1 syndrome, right? So let's talk about some things here, right? They're released to gastroenterology. And also, you know, make a few integrations with all those systems, right? So the first thing should be thinking about, right, in terms of this person having a chronic diarrhea, is you want to think about Zolinger-Elysins syndrome, right? You want to think about Zolinger-Elysins syndrome. Remember, Zolinger-Elysins syndrome, it really, really, really loves to constaria, right? Many people don't realize this. All they think about is, ooh, divine, gastroenter, gastroenter, gastroenter, gastroenter, you know, it increases your acid. Yes, don't get me wrong. Gastroenter will absolutely increase your acid, right? Gastroenter will absolutely increase your acid, right? Because we know that gastroenter will ultimately stimulate your pride of cells and need to make acid, but it can also stimulate your enterocromophine-like cells, right? Which will release histamine, that will then go and act on the pride of cells to make acid, right? So it increases your acid. So, you know, you're going to wear, have all these weird ulcers, like ulcers in the jajunum, right? Again, usually people have, like, peptic ulcers, right? Like, either in the stomach or the doggone. And it's that scene ulcers in the jajunum, that's pretty bizarre, right? Whenever you see stuff like that, person probably has something weird going on in their lives, right?

Like, you know, like, zolongelicin syndrome, right? But remember, the thing is gastrin, though, remember, gastrin is also a pro-chainetic agent, right? So the thing is they can actually give you a zolongelicin syndrome question, and the person has diarrhea as a finding, right? Remember, gastrin is a pro-chainetic agent. That's actually very high-youtinal. Gastrin is a pro-chainetic agent, right? So the MBME, like, one thing they are very big on these days, are giving you things that people don't really know, is not that we don't understand, we actually don't understand the path of this. What people don't think of these things as causes of diarrhea. Remember, in zolongelicin syndrome, because gastrin is a pro-chainetic agent, people can get diarrhea as a result. And medallary thyroid cancer, calcium toning, right? Causes you to secret more, and electrolytes into the lumen of your GI tract. It can cause a secretory diarrhea. That can cause diarrhea, right? So just going to keep those things in mind, even botulism, right? They love to write botulism questions as diarrhea questions in kits on MBME exams. Again, it's something you absolutely need to watch out for. Right? So that's the lumen gelicin syndrome, and how do we treat z-e syndrome? Remember, we can treat it with a proton pump inhibitor, so that it can prevent the formation of acid, right? But now, some other things you want to keep at the back of your mind, right?

With z-e syndrome, you may say, which of the following will be the most likely finding on biopsy of the intestines or any of the stomach? Well, I would really hope that you're telling me that there will be hyperplasia of the pride ourselves, right? And the thing is, unfortunately, those things can actually predispose a person to having a gastric adenocarcinoma, right? Whenever you have this constant, constant, constant inflammation, because you're trying to fix one also after the other. That can increase the presence risk of having like a maltoma, right? They can have a maltoma, but it can also have a gastric adenocarcinoma as a result of that. Now, you may say, okay, divine, why does this person that have MEN1 have poliuria poledipsia? Well, the reason they have the poliuria poledipsia is because they have hypercalcemia, right? They have hypercalcemia. So you may feel like divine, okay, hypercalcemia poliuria poledipsia, how exactly does that work? Well, the thing that many people don't realize is that when you have high levels of calcium, it actually messes up your principled cells response to EDH. Like literally, hypercalcemia causes an effrogenic diabetes in syphilis. So remember, if a genic diabetes in syphilis is not caused only by the metylocycline, is not caused only by lithium, it can also be caused by the electrolyte abnormality hypercalcemia.

This is why whenever you see an immune question of people that have hypercalcemia, it's usually shot with making a ton of urine, drinking a ton of fluid, right? So they essentially have an effrogenic diabetes in syphilis, right? So that's why they can have hyperneetrimia, right? Again, they don't respond to EDH. That's why usually one of the best treatments for symptomatic hypercalcemia is go ahead and give the person fluid because they're usually like profoundly volume down, right? And then just to kind of tee the rest of this up, right? Like, why is the person having their hats, their rings and stuff not fit? God, really hope you're telling me that, oh, the person likely has a acromegaly, right? Remember, acromegaly, right? Yeah, over the age of 18, so it's going to be acromegaly because they have some kind of pitotera, the noma that's making a ton of growth hormone, right? So remember, when a person has a growth hormone excess, right? What is the smart thing you usually do? First thing you do is you check the IGF1 levels, right? Again, they will try to trick you into checking the growth hormone levels. Don't do that, right? That's usually not a smart idea, right? Go ahead and check the IGF1 levels because growth hormone is secreted like, you know, it has like a lot of variations in its secretion. Sometimes during the day, it's really high. Sometimes during the day is really low. So if you catch it at the really low point, you may think like, oh, this person is fine.

No, no, no, no, right? So that's why you check the IGF1 levels first, right? That's going to be your screening test, right? And then after you notice that the IGF1 is elevated, then the next thing you're going to do is you're going to do, you know, after you do any screening test, it would make sense that you do some kind of confirmatory test, right? That's just bio-stats at P, right there, right? So your confirmatory test will be like to give glucose and see the presence of growth hormone suppresses, right? That's the oral glucose or suppression test, right? In general, if a person has failure of their growth hormone to suppress with glucose administration, then that's the agnostic of the person having acromegaly, right? And obviously, after that, you're going to go ahead and get an MRI of the brain so you can find the pituitary, the normal, right? And then you're going to fix this surgically, right? The buzzword you're looking for in an exam is a transphenoidal resection, right? You're looking for a transphenoidal resection, right? A transphenoidal resection. Although if you're also seeing, oh, the person is a poor surgical, can you do what can you do? Well, again, a couple of things you can do for acromegaly. You can actually go ahead and give an octurion tide, right? Somato-statin analogue, remember, somato-statin shoots down the release of many things, right? But if that doesn't cut it, right, you can also give big viso-mant, P-E-G, V-I-S-O, M-E-N-T, big viso-mant.

Big viso-mant is a growth hormone receptor antagonist that can be used to treat acromegaly, right? So again, I'm just, again, you'll be, I know this is a GI review, but again, I'm going to make lots and lots and lots of integrations because the thing is, at the end of the day, the MBM is not linear, right? MBM is more of an integral example, right? So you want to be able to think in multiple dimensions from just one topic, right? So the GI topic, actually, did talk about here was Zolongelicin syndrome, right? Well, you say, again, I kind of talked about in the context of M-E-N-1 syndrome, right? Okay. Now, maybe the last thing we should talk about today, because again, I want to keep this on the 30 minutes and I have a quick life lesson I want to talk about, right? So what if you get a question about like a 29-year-old male, you know, his BMI 17, oh, okay? And then he looks malnourished and then he tells you that, oh, whenever he eats, he's abdominal pain. He's abdominal pain, feels, feels worse, right? He's a little bit of an open, feels worse. I mean, if also if he does not eat, he's a little bit of pain, feels better. So if they eat, they feel bad, if they don't eat, they feel good, right? If you see this, I don't want you to think about a gastric ulcer, right? Remember, whenever people have gastric ulcers, again, it's usually in the antrum, right? It can be caused by many thins, right? It can be caused by heech pylori, right?

It can be caused by NSAI Ds, remember NSAI Ds, right? By inhibiting cycloxygenase, they'll kill your synthesis of persta-glandins. By killing your synthesis of persta-glandins, you're killing that protective effect of persta-glandins on your gastric mucosa, right? And then don't forget, right? Burns, right? Whenever a person suffers a really bad burn, right? That's a curling ulcer, or they have increased ICP, like a cushing ulcer, right? Those things can all cause a gastric ulcers, right? And if I'm only speaking one of the reasons that those things may happen is you may have like a big parts and pathetic drive, right? Remember, your parts and pathetic system through gastronolousin peptide makes you make a ton of gastric, which can make you produce a ton of acid, right? So that's one potential mechanism right there, right? So I think let's go ahead and maybe talk about how you treat heech pylori and then wrap up here. So how you treat heech pylori? Again, remember, you can use a triple therapy, right? So triple therapy was the easier way to remember the what it means, right? Remember the term cap CAP, right? So the C is for claritromycin. The A is for amoxicillin, and the P is for PPI, a proton pump inhibitor, right? But if that doesn't work, then you need to proceed to cordial therapy, right? Cordial therapy is like metronidazole, right? Bissmoof, subcellicylate, tetracycline, and then a PPI, right? Remember metronidazole? Don't take alcohol with it, right?

Because remember, metronidazole has the ability to inhibit acetaldehyde dehydrogenase, right? So the person will have a beautiful vasatodehyde and they can have a disulfuroma side effect. So I'm going to go ahead and stop here. Again, as I do at the end of every podcast, I don't for want to want to learn from any exams. Step one, step to CK, step to CS. Well, that's a now a defunct exam. But let's see step one, step to CK, step three. Preclinical medical exams, third year of self exams. If you're medicine resident, I need children for your med, internal medicine, training exam, or your medicine boards, I tutor for those things. Again, I've had many, many people be successful. And then, you know, if you need application advice for the ERAS process or for the MCAS process again, I've had many successful students. If you have like a tricky application, lots of red flags, stuff like that, just reach out to me. And I'll be happy to give you some more information on pricing and the kind of work I can do with you to really help you put your best for the forward. And then, the next thing I would say is I'd offer classes, especially for the step to CK, step three exams. And also an MBA me testing and strategies class. I'm actually going to be holding one next month. I'm going to be towards the end of next month. I'm going to be making a podcast on that and giving some more information on that. And then, please subscribe to the website, divineinterventionpodcasts.com.

If you're subscribed, then whenever I make a new podcast, you'll get an email notification. I also have a You Tube channel. That's where I put all my videos, divine intervention, USML Podcasts and videos. So please subscribe to that. That definitely always helps. And then, I also have these podcasts on Apple Podcasts, Google Podcasts, Spotify. At least my most recent 150 podcasts are going to be on there. But if you want all the podcasts from episode one, up to the present time, always check the website. That's where it's going to be. I'm divineinterventionpodcasts again with an SADN.com. And so, what's my life lesson today? So, my life lesson today is about something I call crossing the aisle. Crossing the aisle, right? I just kind of thought of it as a topic, right? Because I'm aisle is something that used to go from like one point to another, right? So, what can crossing the aisle mean for many people? You can even go from being poor to being rich, right? You can mean going from having some kind of bad behavior or some kind of addiction, right? Or some kind of mental health crisis to another to being better. It can go from being lazy to being hardworking, right? You can go from being a failure to being a success, right? So, today I'm going to talk about like two key things that can make you cross the aisle in life, right? So, what's the first one? The first one I will say is just not being lazy, right? The thing is, many times people are very lazy.

Again, I know you may be like, wow, we medicine, everyone in medicine is hardworking. That's actually not true, right? Again, and I can say this with a unique perspective, because again, at this point I've worked with thousands of students in my lifetime, right? Like, I've seen lots of medical students, I've seen lots of residents and I've seen lots of attendants that are lazy, right? So, people are actually lazy, and that's the thing that is keeping them on the other end of the aisle, right? You see some people who just don't want to work hard. You see them, they are very slow at the award. Again, folks, if you're lazy, it's going to be really hard for you to be successful in life, right? And further, there's a part of the Bible that says that, CSDOWA man that is diligent in his business, he will stand before kings, not before me men, right? So that's the thing, go and learn from the aunt, right? I love the book of Proverbs, has all these great teachings, right? Learn from the aunt, you slugger, stuff like that, right? So, again, one way you can break out of, you can cross the aisle in life is, is really to just, to not be lazy, right? Just make that change in your life, start being hardworking, start being diligent, right? Pay attention to your duties, right? If you want to cross that aisle from, oh, I didn't do so well on step one, I want to cross it on step 2, CK. To cross that aisle needs hard work, right?

If you know you have poor study habits, change something, do something different, so you can move in the right direction. So that's the first thing that can prevent people from crossing the aisle, right? So, if you're lazy, be hardworking, and you can cross the aisle of life. Now, the second thing I want to talk about is giving excuses. Oh, people are very good at giving lots and lots and lots of excuses, right? People love, love, love, love, love, love, giving excuses. What do I mean by that? They always give one excuse after the other. They talk about, oh, my background makes it hard for me to achieve this thing in life. Or, oh, because I'm a certain, because I'm going to have this kind of disposition, or because of these conditions that we are around the thing is, I know we currently live in a, in a time of life where, you know, sometimes people want to talk about how, in fact, I want to be careful here, so I don't get myself in trouble. But people talk about some background they have that is making it impossible for them to reach certain heights, right? The thing I would say is, if you look, and if you do your research, there are many people that have a, that's background that you see is a disadvantage that have made great things of their lives. In spite of those disadvantages, don't get me wrong. The people occasionally have, the people, not even occasionally, the people have cogent reasons for why they may have to work harder than normal to succeed. Absolutely, right?

Like, being in a certain background, or being in a certain socio-economic status, or whatever, can absolutely present some challenges to achieving certain things in your life. But the thing is, the fact that you have that background, right, is this famous Nigerian musician that I love using the statement, is a gospel musician, he says, don't let your background, let you keep your back to the ground, right? Don't let your background, let you keep your back to the ground. Right, so you see many people, they give one reason after the other, or I mean, this is socio-economic status, I mean this, I mean that, I mean this, I mean that, I mean this, I mean that, I mean, this is a franchise, blah, blah, blah, blah. Again, don't get me wrong, are those things good reasons? Yes, they are. But the thing is, you can overcome those reasons, you can rise above, right? So like, today we really celebrate Martin Luther King, because he rules above the circumstances that exist in his life back then. Again, I know someone who I'm seeing is controversial, again, my apologies, again, I don't really mean to incense anyone or whatever. Right? And I'm trying to be as wise as I can in what I'm seeing right now. But even if you have, and again, like, let me just, let me, let me, let me preface this again. Challenges are unfortunate, right? The fact that a person, you know, obviously if you have fewer challenges, you may be able to move really far in life.

But the thing is, I will challenge you to try to maybe change that mindset that, if all those challenges are keeping you down, or because I feel like many people just use that as an excuse, an excuse, an excuse, an excuse, an excuse. So again, look at Kamala Harris, right? The current vice president of the US. Hey, she's, she doesn't necessarily belong in, she's not necessarily in the majority, right? She's one of, she's a president that you may see, it belongs to a minority population. But guess what? She's kind of broken through all those barriers, right? And now she's the vice president, right? So the thing is, don't let your background be an excuse, right? Don't let your background be an excuse, right? Don't let your background be an excuse. Rise above that background. Again, the fact that you have a certain kind of background does not mean that because of that background, you have a defined kind of future. No, right? You can have a background that presents many, gives you many good reasons, right? For why you cannot succeed. But the thing is you can, you can be a trailblazer, to be honest with you, you have not a Portland Trailblazer's fan. But I really love their, the name of their team, Portland Trailblazers, right? You can be a trailblazer. You can be the first person that has had all these challenges and broke through to succeed, right? So that's the thing like I know many people that are minority populations that have succeeded, right?

So I will encourage you as individuals. Again, I don't mean to incense anyone. I'm just seeing this from a place of love, but really, really trying your life. Stop giving excuses, right? Stop giving excuses. There are many people that have been through much tougher circumstances, right? Much tougher circumstances that have achieved much bigger things, right? Much bigger things, right? Because I just feel like we live in a generation now where people always try to find a reason for why they are down. Find a reason, find a reason, find a reason, find a reason, find a reason. Instead of finding reasons, why don't you go ahead and find solutions, right? Because like for example, there is even this part of the Bible that says that, oh, that you have not yet in your struggle against sin. You've not yet struggled to the point of shedding your blood, right? Like literally, like there are people that have shed their blood because they are trying to do the right thing, right? You are not being, I mean, some countries of the world, people have had to do that. But the thing is, let's say for example, we live in a country like America, for example, right? You have all these advantages, right? Stop giving excuses. Because I can tell you if you go to other parts of the world, there are people that are going through some very touch-was, very ten-wast circumstances. And you're still making headway in life, right? You're still making headway.

I mean, like just take for example from my own personal life experience, right? Probably sharing more than I intended to hear. But from my own personal life experience, I remember back home in Nigeria when I was a kid. We would have exams and all that stuff, you know, where, you know, like here in the US, you get like a syllabus before you take an exam. In Nigeria, then, you actually, we actually did not have like a syllabus. So we, at least the school I went to, we didn't really know when we would have most of our exams. Most of our exams were completely impromptu, right? Most of our exams were completely impromptu, right? So we would have to be in situations where we would like an instructor could walk into the class and say, oh, right, your name, right, your class, T, a sheet of paper, we have an exam, right? So the thing is, if I had given that excuse of, wow, I didn't know that the exam was today, I would have failed, right? I would have failed many exams, but you know, thank God, I didn't, I didn't, I did pretty well for the most part, right? And that was because I was always prepared, right? I could have given the excuse that, man, I don't have electricity at home, right? Because, I mean, there were times in Nigeria where I went months without electricity, right? Electricity is something that in the US, everyone enjoys, without thinking twice about it, right?

So it's like, but in those circumstances, I'm like, oh, divine, go ahead and turn on the candle, go ahead and turn on the carousine lamp, right? To study, right? So I didn't give all those excuses that, oh, humble background, there's no electricity, there's no water, there's no this, there's no that. So stop giving excuses for why you are not succeeding, right? Again, don't let your background put your back to the ground, you can succeed, you can blitz trails, you can move forward, right? If you're putting the requisite effort and you know, if you have got on your side, right? So again, putting the work, right? Again, I'm a, from listening to my podcast, you probably know that I'm a man of faith, but the thing is you can really make headwind life. Again, for me, my faith is something that's very important to me, but you also need to put in the hard work and stop giving excuses, stop being lazy and you can succeed. So thank you for listening to this life lesson, I will see you in the next podcast, God bless you, thank you.

Dysphagia, iron deficiency anemia, and esophageal webs.

Schatzki's ring forms a complete, circumferential ring; Plumber-Vinson involves extra tissue that does not completely encircle the mucosa.

Barium swallow (to visualize the pouch).

Because it risks penetrating the weak point of the esophageal wall, potentially causing a massive mediastinal empyema.

H. pylori infection; the biggest risk factor is H. pylori.

Gastroduodenal artery (GDA) erosion or hemorrhage.

Measuring IGF-1 levels.

Dysphagia, iron deficiency anemia, and esophageal webs.

False diverticulum; herniation through a weakness in the thyropharyngeal musculature (Killian's triangle).

True includes all layers (mucosa, submucosa, muscularis externa); False involves only the mucosa and submucosa.

Nephrogenic Diabetes Insipidus (the kidneys fail to respond to ADH).

PPI + Amoxicillin + Clarithromycin.

Oral glucose suppression test (failure to suppress GH).

Spinal epidural hematoma.

Dysphagia, iron deficiency anemia, and esophageal webs.

False diverticulum; herniation through a weakness in the thyropharyngeal musculature (Killian's triangle).

True includes all layers (mucosa, submucosa, muscularis externa); False involves only the mucosa and submucosa.

Nephrogenic Diabetes Insipidus (the kidneys fail to respond to ADH).

PPI + Amoxicillin + Clarithromycin.

Oral glucose suppression test (failure to suppress GH).

Spinal epidural hematoma.