DIP Episode 214 - Family Medicine Shelf Review Series 5 (GI Final)

Okay, welcome. Good morning. My name is the Vine Number resident. This is episode 214 of the Divine Intervention Podcasts. I'm going to be finishing GI for the Family Medicine shelf. So, if you listen to series, so I'm pretty sure this will actually be series, this should be series number five, if I'm not mistaken. And once I'm done with this series, then we're essentially going to be doing GI for the Family Medicine shelf. So, this is Family Medicine shelf series, review number five, right? And again, I know some of you may be seeing there are many episodes, but the thing is, notice I'm kind of limiting the length of these episodes. Like, for example, if the internal medicine videos, if I cover them to like these kinds of podcasts, they will be like 22 different podcasts, right? So, yeah, so just again, please bear with me. Family Medicine is a very comprehensive shelf. And I'm trying to make this as comprehensive as possible, so that people, you know, if you listen to this, you're like, okay, I've listened to a third complete resource for this exam, especially if you want to like honor the shelf. So, let's just go ahead and jump right into it. So, what if they give you a question about a patient? And the tell you that this patient has like, has been having like bloody diarrhea for the past week, and has regular quadrant ping. What bug are you thinking about? Well, I hope you're thinking about your senior intergalytic, right?

Remember, your senior can cause a bloody diarrhea, but he causes this thing called a pseudo appendicitis, right? So, it kind of feels like Crohn's disease or actually like appendicitis. And then if they give you a question about like an eat patient, right? That has again chronic watery diarrhea. I really hope you're thinking about crypto-sporidium, especially when they tell you that you check the stool and you see acid fast all cysts, right? If you see that, that's that's crypto-sporidio cysts. And then obviously, by pressing recently, completed anti-biotic therapy or lives in a nursing home or just was recently hospitalized for anything, think about C-dif, right? Think about C-dif. Although for the most part, when people have diarrhea, it's usually from a viral cause, right? And for the most part, when people have diarrhea, again, just supportive care. That's all you pretty much have to do. But again, if a person's diarrhea is lasting for a pretty long time, let's say like more than a week, you can consider using antibiotics on the those circumstances. And then if they give you a question about a person that you know like hikes or whatever person that has IG deficiency, and then again has like a chronic diarrhea, like a water-y false-melend diarrhea, think about GRD on the those circumstances, right? And then if you see a song from like a developing country like bloody diarrhea and has like a liver abscess, think about ehistolica, right? And Tamiba, histolica.

And don't forget GRD, ehistolica, those respond very well to metronides, right? And remember that if a person has ehec, right? And terror hemorrhagic, E-coli, O-577, no anti-biotics, right? Because you all increase the presence risk of having a H-US, right? Hemorrhagic urmic syndrome. So you kind of want to be careful with that. And the thing is in general, let me just tell you like a nice, dandy general principle for mbim exams. If a person has, because remember I, you know, sometimes when people have diarrhea, you can give them like lopera mind and all that stuff, you know, to kind of help them with the diarrhea. But the thing is, if a person has bloody diarrhea in any way shape of form, please do not give lopera mind or like diphenoxylate. Diphenoxylate is just essentially like lopera mind, just a different name. Don't give any of those drugs, right? Because if a person has, he has a ehec, and you give them lopera mind, it actually raises the risk of H-US. And if a person has C-DF, if you actually give them lopera mind, it raises the risk of toxic makeup color, right? So that's one thing you absolutely want to be careful of on exams for the most part. And I mean, if we're looking at like certain, like if a person, if you notice that a person has diarrhea and some kind of fat malabsorption, then I'll encourage you to consider is maybe they have Crores disease, especially if it's like a chronic kind of diarrhea, right?

And then there's this thing you want to be aware of known as the osmotic gap with diarrhea, right? So basically the osmotic gap, I almost think of it as like an anion gap for a person's, but for a person's stool, right? And really the formula is like 290 minus the osmotic plus potassium that's double, right? So you take the person's stool, sodium, stool, potassium, add it together, double it, subtract from 290. The way I think about it is if there is a lot of electrolytes in a person's stool, like a ton of sodium potassium, that osmotic gap will be low, right? And that will tell you that, okay, there's a ton of electrolytes, this is more likely to be some kind of secretory diarrhea, right? But if there's not much in a little sodium and potassium, it's just like a ton of just other nasty stuff. They want to think about some kind of osmotic diarrhea, right? So like a lactose, like a lactase deficiency, for example. So an elevated stool osmotic gap, right? So usually it's more than like 100, like millions on a kilogram. That's more like an osmotic diarrhea, like again, like lactase, deficiency, or like my absorption kind of deal. But if the stool osmotic gap is less than 50, right? That means it's mostly likely like a secretory diarrhea. So like maybe like a carcinogenic syndrome or like Vipomas with the WDHC syndrome and all that fun stuff. And then one thing, one trick that may also help you is just this thing for whatever reason, people never appear to hear into this.

In detail, that the person's diarrhea improves with fasting, it's likely going to be an osmotic diarrhea, right? Because if you fast, you're not going to be eating that stuff that can collect in your GI trap, pull out order and cause you problems. But for a person's diarrhea, that's not improved with fasting, it's very likely to be a secretory diarrhea, right? So again, these are just all high-yield things to keep in mind. And I mean, like some classic things, right? Like if for example, you tell you that, oh, a person has like, you know, this is your chronic diarrhea and they have these flushing episodes, that's going to be carcinogenic syndrome, right? And obviously you want to go ahead and check the ayurine for elevated levels of a 5-HTA, right? And then if you get a question about a person that has like a low BMI, it's like super self-conscious and all that stuff, right? I want to think about those people that are kind of like inducing their own themselves, you know, like maybe like using laxatives and all that stuff, right? So people that are like, you know, like using laxatives. And usually, those people that use laxatives, if you measure their stool osmolarities, usually less than 250, right? Having a stool osmolarity less than 250 when you have diarrhea is super weird. So if you see that, that's a very specific finding on MDMS for people that are using laxatives to induce a diarrhea, right?

And then if they give you a question about a person that you know has like, I don't know, like all these recurrent like bolts of pneumonia, let's say these persons in the air like 30s, for example, you know, recurrent bolts of pneumonia, sinusitis and all that stuff. And they keep getting like chronic diarrhea, like yeah, this person keeps getting jadial diarrhea, jadial diarrhea, jadial diarrhea. They want to maybe think about like IG deficiency, right? IG deficiency is something you want to look out for in your test, because if you're deficient in IG, you're not going to be able to protect your mucosal surfaces and jadial have a field day in that person's GI tract, right? And then another thing that can also kind of present like that is CVID, CVID is something that can also cause a chronic diarrhea and recurrent pulmonary infections, right? So for those people, you know, just go ahead and check their levels on needle globulins. And if it's IG deficiency, or just BIG, they'll be low. If it's CVID, pretty much all the immunoglobulins will be low or most of them, right? And then don't forget, right? CISTIC fibrosis, right? Can also cause chronic diarrhea from like pancreatic insufficiency, so you're not making lipase, so you have like a Fatma absorption, right? But again, CF, the person symptoms will not start for the first time, like in their 20s or 30s, no, it'll be something they'll have from birth, right?

And then don't forget that, again, this is something that you can see on a classy family medicine shelf. It'll be one of these questions that people are kind of scratching their heads, but it's like a very simple answer in front of you, right? So if you see a person that's, you know, taking like all these sugar-free candy, or like sour candy, or whatever, or even these things that are like these are like cough drops, right? And the person seems to have all these like diarrhea episodes and bloating, they usually have like pretty pretty prominent bloating symptoms. Just think of like the artificial sweeteners in those things causing diarrhea. I mean, those things actually are pretty prominent cause of diarrhea that you've seen the office on a fairly irregular basis. And then if they give you a question about a person that wants to eat, they have like again, bloating diarrhea, and they have like no alarm symptoms, no anemia, no any like no crap going on. They maybe think about like a lactase deficiency. They may not necessarily put the dairy products in the question, but that's something you certainly want to consider on your exam, right? And then if you see a question about a person, you know, like a young person has like again, bloating episodes kind of feel they have like dyspepsia. And they tell you that when they poop, their symptoms feel a lot better, right?

And again, they have like no e-class, no electrolyte abnormalities on their labs, you want to think about IBS, right? Inflamatory bowel syndrome, right? And again, it's usually young people on MBM exams. And then if they give you a question about a patient and you're like, hmm, this patient is like, it's it's gonna be a woman on your test, right? And she's gonna be like between the ages of like 45 to 60. And you know, she has just chronic diarrhea. Doesn't seem to have any temporal association or consume any food. And then they tell you that, you know, you're like, you're kind of worried if try to have a very valuable issue, nothing is happening. You know, colonoscopy and the colonoscopy is like stone cold normal. If you see that, you want to think about microscopic colitis, okay? So these people will have like it would be like a middle age woman chronic diarrhea. And it will usually be a woman that's probably like on some kind of like chronic NSAID for like a thritis or something or like chronic PPI. And then they'll tell you that, hmm, you don't colonoscopy, you don't see squat, right? If you see that, think about microscopic colitis. And for the most part, you want to, you know, stop the NSAI Ds and the PPI's that those people are thinking. So again, just one of those weird things you want to keep in mind. Then again, don't forget giardia, hiker, pressing that drinks from a stream or whatever, right?

And if they give you a question about a person that again, like has like a chronic diarrhea, maybe fought my absorption, again, young age person. And the person has like like, like you notice that they have like a micro-city canemia, you know, very likely like an iron deficiency, an email kind of picture. Please do not forget celiac disease, right? Celiac disease is one of those things you can almost guarantee you'll see on the AMB exam, right? And again, for those people who want to get IG against tissue transglotaminase. And then if you notice that that IG tissue transglotaminase is positive, then consider getting like, you know, like an eGD and then get some kind of biopsy, right? And for those people, again, gluten-free diet. And the thing is if the IgA is negative, the IgT transglotaminase is negative, you can also get IgG against tissue transglotaminase. Because remember, there is a very strong association of celiac disease with Ig deficiency, right? And then for these people, you want to make sure that, you know, they're kind of least on a diet that's free of gluten, right? And then if they give you again a question about a person that has, you know, like been a big drinker for a pretty big portion of their lives, unless it is not three years ago. And then you notice they give you all these labs, right? And you notice that this person has like a very high blood glucose. Think about a person with chronic pancreatitis.

Again, they're not making IP, so they have pancreatic insufficiency. I mean, if you want to do any kind of, usually if a person like has chronic pancreatitis, you don't really need to do any kind of like diagnostic testing on MDM Es, but sometimes they may get you to pick, like, checking their stool for excess fat. And again, they may even show you like an image. And you see something sneaking across the middle of the abdomen, you see like all this white, right? That's chronic pancreatitis essentially, right? For those people, they need pancreatic enzyme replacement. And then if they give you a question about a person that, you know, has like, has had like previous like receptics, like maybe they were sick that some part of the bowel or they have like slur a derma or they have like the abetigastroparesis. And again, they have like chronic diarrhea with that. Or they may even tell you that, oh, this person has like a macrosidic anime with all these symptoms. I just mentioned. Think about some kind of bacterial overgrowth, right? Remember, bacterial overgrowth, when you have like these like you've resected the bowel or the bowel does you have good motility? People can have bacterial overgrowth from that. And bacteria, they love to consume a person's B12 and fully, right? Don't forget like, they fill up both them, right? That can cause like a B12 deficiency with a mega-loblastic anime, right?

And then if they give you a question about like a middle-aged man and this man has like all these like joint pain, has like neurologic problems or like cardiac problems or like eye problems, think about we pose disease, right? From like a Traferema we apply, right? And for the most part you actually need to do like a biopsy, like you need to do like an each day of biopsy of the small intestine. And those people need like treatment for essentially like like a year, right? So just some like they need to be on antibiotics and need to be only consistently for a year. And then what if they give you a question about a person that goes to like some, you know, like, I don't know, like, goes to like India or goes like Puerto Rico. And then the person comes back and then the person has like this chronic barrier like weak loss, they have like fatty stools. I want to think about like tropical spru, right? These people travel to the tropics and then they kind of get into trouble. People don't really understand the battle physiology behind the tropical spru to be honest. And really the way you treat it is kind of weird on the exact way. Actually treat these people with like either with like, you know, like back trim, basically any cell phone or might do or you can use like tetracycline, right? And then you add folic acid for those folks, right? And again, G yardia, I don't I pretty sure I mentioned this a few minutes ago, you treat a mantra, not it is all right?

And you check the for the anti, to make the diagnosis, you just check for the anti-genius stool. And that's pretty much it, right? And again, celiac disease, I kind of talked about it already again. Has this associated gluten? And the way they usually said this celiac disease question or probably like they'll have like, they may have like fat malabsorption, they may have like a micro, micro-cidic anemia, because celiac usually involves the small bowel, right? And your iron is reabsorbed in the blood number, right? So if your door, there's no working right, you get a micro-cidic anemia with that from iron deficiency, right? And then these people may have like dermatitis, a pretty formus, right? So it's like they'll have like this rash on the extensor surfaces. Remember that typically responds to dapsal. And they can also have osteoporosis. In fact, one thing that your friends at the MD Me can do for your family medicine shelf is they can give you a question where they describe a person that pretty much has celiac disease. And then they can ask for your next step in management. And it can actually be to do like a check like they're born like mineral density, because again, people, there's a very strong association between celiac disease and osteoporosis, right? And the thing is because celiac disease is an autoimmune disease, right? Like this is one mantra that I've seen like maybe like 95% of the time on MD Me exams, that detail any kind of autoimmune disease.

When a person has one autoimmune disease, they have a pretty high risk of having another autoimmune disease. So if they are giving you an autoimmune disease question on an MD Me exam, when they are talking about the medical history, you'll almost always mention some other kind of autoimmune disease those people have, right? And in fact, if they ask you like an epidemiology question on celiac disease, the most common like collocalizing autoimmune disease, you may find the people with a history of celiacs is like type 1 diabetes and also like Hashimoto's, right? So those are things to keep in mind. And the thing is again, they can give you like a question about a person that has like multiple autoimmune diseases and then they throw in a risk factor question and say, oh, which of the following historic factors in this patient is the biggest risk factor for small bowel lymphoma? You want to think about a celiac disease under those circumstances, right? And the thing is people on MD Me exams can actually have celiac disease without having Hashimoto's. Because the thing is think about it, where do you think thyroid hormone gets reabsorbed in the body? It actually gets reabsorbed in the GI tract, right? So if, or let me let me let me know completely this much, let's say they give you a question about a patient.

This patient has a history of Hashimoto's and this patient is being treated with synthetic, you know, like liver phyroxy and all like triadal phyrony and you're like, man, this person doesn't seem to be getting better and they have fat bowel absorption with that. Then you actually be a very bizarre but classic celiac disease presentation on exams. Because the thing is if your small intestine is not working, if you're taking thyroid replacement therapy, it's not going to work, right? Because you're not going to be able to reabsorbed, right? So that may be so pay attention to this presentation. This is actually a very high yield thing to know for exams. They give you a question about a person that has Hashimoto's. This patient is started on thyroid hormone replacement therapy, but you don't seem to be observing any effects from that thyroid hormone replacement therapy. And they tell you something about this person having like fatty stools and all that stuff. Think about celiac disease on those circumstances. Because again, your friends at the MBME color realized that you know all these testing resources and whatnot have you know puddles classic questions where a person is taking like some kind of drug and they're taking thyroid hormone and that drug maybe binds up the thyroid hormone or whatever jazz, right? So just going to keep that at the back of your mind. That can be like a new because the thing with the MBME is over the last like eight, nine months.

That's kind of making people scared of the exam is they are big. They are still seeing classic disease presentations, but they are seeing those classic disease presentations in unusual formats, right? So that's just something I want you to watch out for on exams. And again, don't forget that the antibodies against tissue trans glutamines and not the only celiac disease antibodies, right? Remember, you can also see like antibodies against anti-endom micelle antibodies and antibodies against gliadid, right? And again, they can ask you a special question and say like, oh, a patient has a histrocellular disease, they're starting a gluten-free diet and their symptoms do not seem to be and they will say, what's the most likely cause of this patient's philiotrospaunt of therapy? That will just be a non-adherence to their to their diets, right? Again, it's just one of those just simple things, what people tend to overthink on exams, right? And again, don't forget, see that disease can cause like, because again, you can also torture the terminal elium so you can get like a fat soluble vitamin deficiency. So you can bleed from vitamin K problems, you can have like rickets, sociomalicia from vitamin D problems, right? Those people need like cosmol vitamin D essentially. You can have like e-conthusitis on a bloodstream from a vitamin E deficiency.

They can even get a tuxia from that or they can get like, my blindness from vitamin A deficiency or they can get like, skin, hypercarotosis, right? So again, those are all things you want to keep at the back of your mind. And again, you can decrease a person's risk, right? Remember, whenever you can have like a lifestyle change that can decrease a person's risk of cancer, the friends at the MBM love to test those things, right? So don't forget, if you get a gluten-free diet, it will actually decrease the incidence of a small bowel and forearm, right? On MBM exams, right? And people that have a celiac disease, right? So again, celiac disease, the way you make the diagnosis, you check the antibodies first and then after that, you need to do a need to do a BIOPC, right? Of the GI tract. So again, those are just all things you want to keep at the back of your mind, for exams. And then if they give you a question about a person that, you know, a young person has, you know, like just chronic bloodied diarrhea, think about, and this person, let's say, the tale of whenever they smoke, the symptoms get better, think about all three difficulties under those circumstances. But if a person has predominantly like watery diarrhea, and you know, they have like a lot of abdominal pain, and they have like, you know, like a lot of like fever, like chronic fever, they have like these fistula salisions, right?

So like maybe poop is coming out from the skin, or they have like a poop coming out through like the urine, because they found like a fistula from the GI tract to the bladder. Think about, unless you see the symptoms get worse with smoking, think about cruises, these are under those circumstances, right? And again, some of just these basic science details from step one, you may still see on step two, see can also your family medicine shelf, right? So people that have also difficulties, they don't have skip lesions, right? Remember the lesions are continuous, they may have like these cryptopsesies. And again, it only affects the colon, right? And it always affects the rectone, MBME exams. Contrast this with like cruisesies, right? Where they'll have like skip lesions, they'll have like granulomas, if you biopsy those people's GI tract, and they'll have like transpiral involvement, right? So those are things you want to keep at the back of your mind. And then don't forget, like one thing your friends at the MBME tend to fist stop are just the other things that you may see associated with these inflammatory bowel diseases, right? Especially cruisesies, right? These people may have like, upper ulcers, they may have like ankylose and spondylitis, they may have like essentially like those are seronegative or spondyl orthropathy, especially like the IBD associated arthritis, right? Then you have like a aritheminal dosa, right?

So that'll be a painful lesion on the works remedies, they can have like pyrodemerc and granulsa. Basically pyrodemerc and granulsa looks like a their aritheminal dosa, where they have like a granulsa appearance to the skin, right? Then you have like U Vitis, you may have like scleritis, right? So you may have like eye problems with those. And really the way you diagnose cruises or UC is you go ahead and get a colonoscopy or biopsy and that's all you need. And for the most part, one thing you may see that you may want to be careful about on the example, this probably more so step 2 CK. If you suspect the prison has cruises or UC, you don't want to get a barium swallow on those people ever, right? Because the thing is, especially in people that have all sort of collitis, you can actually trigger toxic mega colon, right? So that's something you just want to watch out for. Now if the person is going through like an acute flare, for the most part you treat those people steroids, that's pretty much all you need to do. And then for maintenance therapy, right? You want to go ahead and put them on like these aspirin derivatives, right? So like mesalamine, so facalazine and all that stuff, right? Basically those drugs deliver acetylocelacetic acid to the colon, right? And again, these people, these are those people because you may see these like pneumococcal vaccination questions on your test because again, it's a family medicine shelf.

Remember people that have just chronic diseases in general, like IBD, those people deserve those pneumococcal vaccines, right? And they should give you a flu vaccine every year, like everybody should. And then remember that if a person has like, you know, like these IB Ds and it's not responding to these like five ASA agents like mesalamine or facalazine, you can consider studying those people on like the TNF inhibitors, right? So like infleximab, adalimiumab, gollimiumab, although don't forget those people, they need to be tested for TB and for a happy B before you start treating them with any of those therapies. And then one nice way that your friends at the NBME love to give like a nice step one throwback on exams with even like this family medicine shelf is some people that actually get IBD, right? That have IBD, the actually not like six mechapal purin is a fire print. Don't forget the association with, again, you may say, oh, divine, this is step one crap, I don't care about this. I wish all the best. But basically the big thing I want to keep in mind is that if people have, if people have IBD, right? And the Abin Trinot is a therapeutic six mechapal purin. What if you're careful of these drugs that I use for gout like fabucsul stat or alopurinol because those drugs inhibit xanthenoxidys and xanthenoxidys metabolizes six MP and is a fire print to inactive stuff, right? So if inhibiting xanthenoxidys those drug levels will build up.

And then in general before you start a person on any kind of therapy for like is a fire print of six MP therapy just again for purposes of MBME exams. Check their levels of TPMT, TPMT enzyme known as a fire purin method transferries. If you have no activity of this enzyme, you are very high risk of toxicity from six MP and is a fire print. In fact, about one in 300 people lack this enzyme, right? So just check for TPMT activity again. It's just one of those bizarre unusual new MBME questions you could see that could kind of throw you off balance. But hopefully you would not because you're listening to the podcast. And remember, ulcerative colitis is curable if you get rid of those people's colons. So you do like a proctoclectomy, so you get rid of the rectum and the colon, right? Procto means rectum. And don't forget the associated between ulcerative colitis and and primary sclerosis in colonitis, where like your intranetriopatic boundoc cells spread up TNK may be positive, right? You'll have a direct type of herbivineia. Their outforce will be high, their GGT will be high, right? So those are just all things to watch out for. And I know I talked about my curoscopic colitis. For the most part, the way you actually treat it is you can treat it like an anti-diarrholy agent like Loparamide, or you can give those people like oral butesonite, like an oral colicosteroid. Again, stop the inciting agent, stop the ibuprofen, stop the PPI and all that stuff.

And maybe triggering their symptoms. And then one thing I just want to talk about, if you give you a question about a person that has a histral chronic diarrhea, and then they tell you that, oh, you get a colonoscopy, and you notice that those people have like this like black appearance of the colon, like almost like black colon, think about something called a melanosis coli, it's been like you're going to do squat for that. And then again, I've kind of talked about IBS already, right? They give you a question about a young person, they have like bloating, these like weird non-specific, but no symptoms that get better. When the poop or the tell you that, oh, the stool has changed form, the stool has changed frequency, that's essentially like the wrong criteria that I'm exposing right now. Think about IBS. IBS, there's many types, right? There's IBS, C, IBS, D, IBS, M, like the mixed IBS. And for the most part, again, people with IBS, so name me, me, I'm saying I'm going to have a lab of normalities, they're not going to have physical exam of normalities. And for the most part, when people have IBS, there are many things you can use to treat them right. So like if a person has IBS, and they have like IBS, you can give them like a tricyclic and tidy present, you will essentially be taking advantage of its anticholinergic effects to fix their symptoms.

If a person has like IBS, like IBS with constipation, you can give them these serotonin agents like Lobi prostone, you can give them Lenaplo tied L-L-I-N-A-C-L-O-T-I-D-E, right? Lenaplo tied that can help with IBS, C. IBS, the again I said, you can try tricyclic and tidy present like in me, you can give them Loparamide, right? Refaxing in me won't be a drug you may see on exams. And then there's this drug you may see and there is your friends at the MBA may begin to care more about this drug. It's known as alo-setron. It's a serotonin agent. It's very good actually for IBSD. But the thing is, you want to be careful giving people alo-setron. You typically want to try other agents first before giving alo-setron. Alo-setron actually has a very strong association with ischemic colitis, right? So you just kind of want to be careful with that when you're prescribing that to people. And then as I wrap up here, if you give your question about like an old person with like painless bloody bowel movements, think about diverticulosis. Diverticulitis, right? It will be an old person, left low collagen pain, fevers. You make the diagnosis with a CT scan or IV contrast. Although usually the symptoms are classic, you maybe don't even need to do any kind of imaging. And for the most part, those people you kind of put them on like a clear liquid diet, you'll give them antibiotics, usually like the combination of like c-pran metronides all.

And don't do a colonoscopy while they're going through the episode, right? You can perf the abdomens and they'll be like, you know, like bad. And one weird thing, it want to keep in mind is, if a person has like one episode of diverticulitis and then they have like a second episode, and for the most part, you want to go ahead and refer them to surgery after the second episode so that you can reset that part of the colon. But the thing is, weeks after a person has diverticulitis, you need to, you absolutely need to consider sending those people for like a colonoscopy just to roll out a colon cancer. So just things to keep in mind for exams. And then I think let me just wrap up here. Let me just say the last thing I want to talk about, if you give your question about a person, I've talked about this in many podcasts before, like the person with a history of e-fable or a cell M.I. and they have like sodium onset, CV abdominal pain, think about acute mesenteritis, Schemia, right? For the most part, you do like angiography, fix the problem. If bowel is dead, then you need to obviously refer them to surgery so that the bowel can be resected. And in chronic mesenteritis, Schemia will just be a person that has like really bad vasculot disease. And whenever they eat the ability hurt, so they lose a ton of weight because they don't eat, right? And again, you do angiography to me, the diagnosis, like a CT angiography or an MR angiography.

And that's pretty much all I think I'm going to say here. So I'm pretty much done with this. So as I do at the end of every podcast, I offer children for many exams. Step one, 2 CK, 2 CS, step three, preclinical med school exams, 30-ish-off exams. I do booster courses for step one, it's 20 hours, step two, six, step three, two, 15 hours each. And then if you medicine resident, you need to learn for like your board exams or the in training exam, reach out to me. If you're a college student, you need to learn for like Gen CAM, OEM, physics, biochem, histology, physiology, et cetera for all those things. And then if you need coaching, let's say you're medicine applying to residency so like an ERAS app or a college student applying to med school so an AMCAS app. I go for like one-on-one coaching, one-on-one advising for those exams. Again, I have like like one year's worth of admissions community experience at a top two med school actually, right? So the vast majority of people have worked with that much of their first choices. So if that's something you're interested in, just reach out to me. It'll send me an email through the like reach out to me through the website, so you can send me an email at the Divine Intervention Podcasts with an Savvn.gmail.com. Please subscribe to the website, subscribe to the podcast, the Apple Podcasts, Spotify, and Google Play. And I will see you in the next podcast. Have a wonderful rest of your day. Thank you so much for listening to me.

God bless you. See you next time. Thank you.

An elevated stool osmotic gap (usually >100 mOsm/kg).

Osmotic diarrhea.

Salmonella species (or other invasive bacteria like EHEC).

Acid-fast cysts.

Celiac disease involves the small bowel (often presenting with malabsorption), while Crohn's can affect any part of the GI tract. Both cause fat malabsorption.

Type 1 Diabetes Mellitus and Hashimoto's thyroiditis.

Positive antibodies against tissue transglutaminase (tTG IgA).

Lactase deficiency.

Crohn's disease (or other IBD).

Ciprofloxacin + Metronidazole.

Stool osmolarity less than 250 mOsm/kg.

Seronegative spondyloarthropathy.

Microcytic anemia (iron deficiency) and osteoporosis/osteopenia.

Positive antibodies against tissue transglutaminase (tTG IgA).

Lactase deficiency.

Crohn's disease (or other IBD).

Ciprofloxacin + Metronidazole.

Stool osmolarity less than 250 mOsm/kg.

Seronegative spondyloarthropathy.

Microcytic anemia (iron deficiency) and osteoporosis/osteopenia.